CFNM UndergradApplication by TBd92btU


									                                                                                                  FOR INTERNAL USE ONLY:
                                                                                                  Received by:

                      NANOSCHOLARS PROGRAM
                                  (Undergraduate Application)
                                              Print and return application to:
                                                Joyce Lockhart
                  Thomas W. Cole, Jr. Research Center for Science and Technology, Room 3005-D
                                             (404) 880-6784 (Office)
                                              (404) 880-6640 (Fax)

                                                      or mail to:
                                  Center for Functional Nanoscale Materials (CFNM)
                                              Attention: Joyce Lockhart
                                              Clark Atlanta University
                                               223 James Brawley Dr., SW
                                                 Atlanta, Georgia 30314

                                                        or Email to:

CHECK ONE (Double click to check appropriate box)
  I have applied for admission to Clark Atlanta University
  I have been accepted as a student at Clark Atlanta University
  I am enrolled at Clark Atlanta University

Name:                                                                            Male:               Female:
         Last                         First                      Middle

Place of Birth:                                                Birth date:
Citizenship:                                                   Email Address:
Overall GPA:                                                   Science GPA:

How Do You Identify Yourself?
  African American                                                White
  Hispanic/Spanish Surnamed                                       Asian American
  Native American/American Indian                                 Foreign National
  Other (Specify):

Mailing Address                                              Present Mailing Address
  Number and Street:                                           Number and Street:
                City:                                                        City:
               State:                                                      State:
                 Zip:                                                        Zip:
          Telephone:                                                  Telephone:

High School Attended:                                                       Year of Graduation:
Present Classification:                                                     Major:
Application – Undergraduate CFNM Program                                                                      Page 2

Please give your scores on any of the tests below that you have taken
SAT Verbal:            SAT Math:                ACT:
MCAT BIO:              CHEM:                    PHY:                                             PS:
SA:R:                  SA:Q:

Incoming Freshmen: What was your overall high school GPA?                                      Science GPA?

List the college science and mathematics courses that you have taken or in which you are currently enrolled.





List honors or awards that you have received during the past three years (including high school)

List any extracurricular and community service activities in which you have participated and/or are
currently participating.

Give the names of the instructors who have taught you and are sending a letter of recommendation.
       A. Name:

        B. Name:

Clark Atlanta University does not discriminate on the basis of sex, race color, age, religion, sexual orientation, national or
ethnic origin or physical handicap.

This program is sponsored by the National Science Foundation (NSF)/Center for Research Excellence in Science and
Technology (CREST)/Center for Functional Nanoscale Materials (CFNM) supported grant (GRANT #HRD-0630456)
Application – Undergraduate CFNM Program                                                Page 3

Please attach to this application a typed paragraph (200 words or less) describing your research
interest and career goals.

My research interest and career goals . . .

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