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LSAMP 2012 Application DOC by Z9s2NXTJ

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									           Garden State-LSAMP APPLICATION FORM
         Montclair State University - LOUIS STOKES ALLIANCE FOR MINORITY
                          PARTICIPATION IN THE SCIENCES

                                         Fall/Spring 2011/2012
                                           Please print or type

NAME_____________________________________________________________________________

ADDRESS__________________________________________________________________________

        __________________________________________________________________________

TELEPHONE _________________________________________________________________________
                Area code             Number

Email Address: _______________________________________________________________________

ETHNICITY:      Hispanic or Latino      Yes      No

RACE:  African-American or Black        Alaskan Native           American Indian (Native American)
       Asian  Native Hawaiian or other Pacific Islander  White or Caucasian
       Other. Specify ________________________________________________________________

GENDER           Female                        Male

CITIZENSHIP:  US. CITIZEN  NATURALIZED CITIZEN                             FOREIGN

HIGH SCHOOL ________________________________________________________

COLLEGE (If applicable) ____________________________________________


COLLEGE OR UNIVERSITY CLASS LEVEL IN THE FALL 2011 (ENTRY SEMESTER AT MSU)
       Freshman   Sophomore    Junior      Senior

YOUR PROPOSED MAJOR AT MONTCLAIR STATE UNIVERSITY _________________________________




LIST THE SUBJECT(S) THAT YOU WOULD LIKE TO STUDY AT MONTCLAIR STATE.




WHAT ARE YOUR PLANS AFTER GRADUATING FROM MONTCLAIR STATE?
                    Montclair State University, MSU Garden State-LSAMP, Academic Year Application Form
                                                        Rev. 10/2011
                                                           2




BRIEFLY DESCRIBE YOUR CAREER GOALS.




DESCRIBE WHAT YOU BELIEVE ARE YOUR GREATEST STRENGTHS AS A SCIENCE/MATH
STUDENT.
(science, mathematics, computer science, biology, chemistry, physics, environmental, etc.).




                   Montclair State University, MSU Garden State-LSAMP, Academic Year Application Form
                                                       Rev. 10/2011
                                                              3


THE NEXT TWO QUESTIONS ARE OPTIONAL. HOWEVER, YOUR ANSWERS TO EITHER OR BOTH OF
THESE QUESTIONS MIGHT HELP US TO QUALIFY YOU FOR THE MSU-LSAMP PROGRAM.

Describe any cultural, social, or economic barriers you believe you have faced in your pursuit of
education.




Describe how your participation in the MSU-LSAMP program will contribute to the program's goal of
broadening participation in the sciences and the future of the discipline.

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Mail or deliver to:
LSAMP/MSU
College of Science and Mathematics
ATTN: Dr. Quinn Vega
Science Hall, Room 107-A
Montclair State University
Montclair, NJ 07043

National Science Foundation Grant HRD-09_______ supports the Garden State-LSAMP

                      Montclair State University, MSU Garden State-LSAMP, Academic Year Application Form
                                                          Rev. 10/2011

								
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