SPRING 2016 HCC NSF AMP PROGRAM STUDENT APPLICAITON

Transcription

1 SPRING 2016 HCC NSF AMP PROGRAM STUDENT APPLICAITON AMP APPLICATION FORM DEADLINE: DECEMBER 15, 2015 Please submit this form with either an official or unofficial transcript or two letters of recommendation from an HCCS- or other university or high school science instructor by DECEMBER 15, Last Name* First Name * HCC ID # * Current Mailing Address * City * State * Telephone (xxx) xxx-xxxx * Fax * Major/s * Overall GPA * GPA in Major/s * Personal Information and Family Education Male Female CITIZENSHIP United States Citizen United States Permanent Resident Foreign Student, Citizen of

2 ETHNIC BACKGROUND African American Asian American Hispanic Native American Caucasian Other Family Education: Please state the highest level of education received by your: Mother: High school diploma Some college College degree Post-graduate Father: High school diploma Some college College degree Post-graduate Applicant Academic and Educational Information School Currently Attending/Last Attended: The above listed educational institution is a: High School Two-Year College Four-Year College Graduate School Please list all high schools and colleges attended: School Dates Attended Degree GPA What is your intended major/field of study/specialization? How many semester hours to you intend to carry while participating in the HCC NSF AMP program? What is your anticipated completion and/or transfer date from HCC? Do you plan on transferring to a University? Yes No If yes, which University?

3 Please list and describe the science/engineering lecture and laboratory courses you have taken*: Have you had any previous research experience? Please describe*: Statement of Purpose*: Why do you want to participate in the HCC NSF AMP program Academic Goals*: What are your academic goals?

4 Certification and Release I, THE UNDERSIGNED, HEREBY CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I AUTHOIRIZE HOUSTON COMMUNITY COLLEGE TO RELEASE THE INFORMATION CONTAINED WITHIN THIS APPLICATION (INLCUDING ACADEMIC RECORDS AND PERSONAL BIOGRAPHICAL INFORMATION) TO MEMBERS OF THE SELETION COMMITTEE AND AGENCIES/DONORS PROVIDING FUNDS FOR THE SCHOLARSHIP AND THE REEMS PROGRAM. I UNDERSTAND THAT THE NAMES OF THE SCHOLARSHIP AWARDS RECIPIENTS AND NAMES OF THE HCC NSF AMP SCHOLARS MAY BE PUBLISHED IN AREA NEWSPAPERS AND RECIPIENTS MAY BE ASEKD TO PROVIDE A PHOTOGRAPH. NON COMPLIANCE WITH ELIGIBILITY REQUIREMENTS OF THE REEMS PROGRAM MAY RESULT IN MY REIMBURSEMENT OF MONIES TO THE RESPECTIVE SCHOLARSHIP AND/OR PROGRAM FUNDING AGENCY. ANY DEBTS OWED TO HOUSTON COMMUNITY COLLEGE MUST BE PAID PRIOR TO THE DISBURSEMENT OF SCHOLARSHIP/ RESEARCH STIPEND MONIES OR ENTRY INTO THE REEMS PROGRAM. ABOVE STATED AND ATTACHED INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE HCC TO REQUEST, RECEIVE, AND RELEASE INFORMATION CONCERNING MY ACADEMIC AND FINANCIAL STATUS TO/FROM THE HCC REGISTRAR. *STUDENT S SIGNATURE *DATE * Required Fields APPLICATION CHECKLIST COMPLETED APPLICATION FORM: Please do not forget to sign OR electronically sign the application NEXT PAGE UNOFFICIAL TRANSCRIPT: Most recent college or high school academic transcript showing all enrolled, completed, and transferred college credits. This transcript must include your most recent grades. ADDITIONAL DOCUMENTATION: Attach additional documentation as needed to comply with the various requests for personal and work related information.

5 NOMINATION FORMS: From your current academic advisor, teacher, or professor who can discuss your leadership, academic and personal achievement, as well as your potential for future success. Please mail, fax or hand deliver the complete application package to the following address by 6 PM on September 1, Bartlett M. Sheinberg Center Director West Houston Center for Science and Engineering 2811 Hayes Road Suite A.408 MC 1524 H Houston, TX whc@hccs.edu Fax: Phone: Mobile Phone: FOR INTERNAL USE ONLY: DATE COMPLETED STUDENT APPLICATION RECEIVED: DATE RECOMMENDATION LETTER 1 RECEIVED DATE RECOMMENDATION LETTER 2 RECEIVED ADDITIONAL RECOMMENDAITON LETTER 3 RECEIVED