COIL-Admissions by panniuniu

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									Collaborative Open Innovation Lab (COIL)
Program Admissions Application (PAA)
COIL is offered through the College of Engineering and Computing Division of External
Programs. Participants must complete a Program Admission Application (PAA) that will be
reviewed and accepted by the COIL Program Director prior to payment of participant fees.
Applicants who wish to qualify for the Student Innovator or Innovator in Residence must
complete the appropriate section of the PAA. If you do not wish to join COIL as a Program
Innovator you may purchase monthly or annual access. There are no fees associated with
application submission and review. You can obtain the PAA and fee payment system at:
http://externalprograms.fiu.edu/coil

                               Applicant Information
Name

First Name:
Middle Name:
Last Name:


U.S. Social Security Number

Social Security #



Telephone Number
Home Telephone #
Cellular Telephone #
Preferred Phone #                                 (1 - Home Telephone 2 - Cellular
Telephone)


Email Address
Preferred Email:




Home Address
Address Line 1:
Address Line 2:
City, State:
Zip Code:
County:




COIL Admissions: 20110505SL                                                            1
Demographic Information (Please enter the appropriate Number wherever
necessary)

Marital Status:                           (1 - Married   2 – Single)


Date of Birth:                             (MM / DD / YYYY)


Gender:                                   (1 - Male 2 – Female)


Citizenship Status:                        (1 – International     2 – Permanent Residence 3 –
U.S Citizen)



Country of Citizenship:


Country of Birth:


Veteran of the U.S. Military:                 (1 – Yes 2 – No)


Please fill out the following if you are not a U.S. Citizen:

Visa Information


Please indicate the visa type you will hold while attending FIU




The following items are only required if you wrote down AR-1 Permanent
Resident:


Permanent Resident Card #


Permanent Resident Card Issue Date


Permanent Resident Card Expiration Date



COIL Admissions: 20110505SL                                                                     2
                              Emergency Contact

Name

First Name:


Middle Name:


Last Name:


Relationship to Applicant:

Telephone Number


Home Telephone #


Cellular Telephone #




Email Address
Preferred Email:


Other Email:


Home Address
Address Line 1:


Address Line 2:


City, State:


Zip Code:


County:




COIL Admissions: 20110505SL                       3
                              Participant Background

If your answer to any of the questions below is yes, you are required to
provide a written explanation of the event. In addition, you may be required
to furnish FIU with copies of all official documentation explaining the final
disposition of the proceedings.

Have you ever been subject to disciplinary action or do you currently have
disciplinary charges pending by an educational institution for academic
misconduct, such as cheating? (You do not need to disclose any academic
dismissal, suspension, or probation that was due to poor grades.)

                              (1 – Yes 2- No)

If yes, please briefly describe the circumstances of your misconduct.




Have you ever been subject to disciplinary action or do you currently have
disciplinary charges pending by an educational institution for behavioral
misconduct, such as fighting?

                              (1 – Yes 2- No)

If yes, please briefly describe the circumstances of your misconduct.




COIL Admissions: 20110505SL                                                  4
You do not need to disclose information about minor traffic violations.
However, you must disclose information if the traffic offense involved
illegal drugs or alcohol or if any person was killed or hospitalized as a
result of an accident in which you were charged for a traffic violation. You
do not need to disclose information regarding any criminal offense record
which has been expunged according to applicable law. You must disclose
information if charges were dropped or not prosecuted because you were
granted any type of pretrial diversion. Failure to disclose this information
may result in revocation of admission.

Have you ever been convicted of, or charged with, a criminal offense or are you
currently the subject of any criminal proceedings?

                              (1 – Yes 2- No)

If yes, please briefly describe the circumstances of your misconduct.




COIL Admissions: 20110505SL                                                       5
                              Program Innovator Statement

Applicants who wish to qualify for the Student Innovator or Innovator in Residence must
complete this section of the PAA. As an innovator you have distinguished yourself with your
vision and desire to execute a great technology project. The Dean of the College of
Engineering and Computing recognizes participants who are willing to commit to seeing
their vision and execution through by providing recognition to professionals and students.
Participants can apply and receive the following recognition:

     Student Innovator: Is a title awarded a student or team of students who are
      building a cool technology project with the assistance of an experienced mentor.

     Innovator in Residence: Is a title awarded a professional who is developing an
      innovative technology project that engages the FIU community and has the potential
      to make a local, national or global impact.

Program Innovators are considered COIL community leaders and receive special privileges,
like reserving design room and equipment in advance, and are consulted in the
development of the COIL program.

1. If you are apply for Student Innovator complete the blank with “1”. If you are applying for
Innovator in Residence complete the blank with “2”.
________________


2. Please describe your technology project in two or three well-written paragraphs
and how you are relevant to the Program Innovator position you are applying for:




COIL Admissions: 20110505SL                                                                  6
3. Are you currently working with any mentors, advisors, or others that can assist
    you in this project? ______________ ( Y/ N). If N COIL will provide you assistance to
    identify such a mentor.


4. What is the most challenging aspect of your project?




5. What type of resource do you need to complete a prototype of your technology?




6. Assuming you had those resources how much time do you believe it will take to
    complete your project?




COIL Admissions: 20110505SL                                                             7
I do hereby swear that all of the information provided above is correct. I
understand that a false statement in this affidavit will subject me to
penalties for making a false statement pursuant to 837.06 Florida Statutes
and to BOR Rule 6C-7.005 F.A.C.

                       Please put your initials in the block
                                    Judicial Status

Failure to answer these questions will delay the processing of your
application and we will be unable to render an admission decision.

                                    Applicants Initials

By putting my Initials below, I hereby grant permission to the Division of
External Programs at Florida International University to act on my behalf in
processing all my paperwork for admission into the Collaborative Open
Innovation Lab Program.


Applicant Initials:

Date:             /           /              (MM / DD / YYYY)

Please review your application and once you are sure that you have filled
out all the information that is required, please save a copy and send it to:
addmissions@coil.fiu.edu




Florida International University
College of Engineering and Computing
Division of External Programs
10555 W. Flagler Street, EC 2427
Miami, FL 33174




COIL Admissions: 20110505SL                                                    8
COIL Admissions: 20110505SL   9

								
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