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FOR INTERNAL USE ONLY: Received by: Date: 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: email@example.com 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. Biology Mathematics Chemistry Physics Psychology 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: Department: College/University: B. Name: Department: College/University: 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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