First Name:

Last Name:

Gender:

Date of birth (mm/dd/yy):

Citizenship:

E-mail address:

Current Address (include City, State & Zip):

Current telephone:

Permanent Address (include City, State & Zip):

Permanent telephone:

College or University:

Major and minor:

Year in college:

Anticipated graduation date (mm/yy):

Name of accompanying faculty member:

Statement of career goals
Upon completion of your undergraduate studies, do you plan to apply to graduate school, enter a profession, etc.?

Statement of purpose
Please include why you wish to participate in this program. Note any previous research programs or projects in which you have participated and be as inclusive as possible. State whether you would want to continue to work in a research area in which you have had prior experience or would prefer to pursue a new area of interest.

Where did you learn of this MRSEC opportunity?
    Department head at your institution
    Faculty member at your institution
    Undergraduate at your institution
    Other

If other, please indicate where.