Include Middle Name, Must Match Name on Government Issued ID

ADMINISTRATIVE INFORMATION GUIDE

Full Name:

(Include middle name, must match name on government issued ID)

Name you would like to be called:

Program (BLUR, CCI, STAR, SULI):

Term (spring, summer or fall):

____ I will accept the appointment to the LBNL undergraduate internship and I commit to attending the entire program, meeting all program requirements and participating in all program activities. I understand that failure to do so may result in termination from the program.

_____ I cannot accept the appointment.

Please provide the date of your last final exam:

Please confirm date of your last day of school:

School Address, City State:

School Phone:

Permanent Address, City State:

Permanent Phone: Cell Phone:

Email:

(CSEE will primarily communicate with you by email, be sure to give an address that you will be checking regularly!)

U.S. Citizen?

If not, please list your country of citizenship and Permanent Resident Alien number:

Country of Citizenship:

PRA # and Expiration Date:

Scan a copy of your Permanent Resident Alien identification card and email it to , , or accordingly, within 14 calendar days of the date of Offer Letter. You must also present the card on the first day of your internship in order to be badged.

Date of Birth: Gender:

Place of Birth (City, State/Province, and Country):

Are you a returning affiliate or former employee?

Class Standing (junior, senior, recent graduate, etc.):

Academic Major:

Do you currently have medical insurance?

Please note you are required to have medical insurance to participate in any CSEE internship.

EMERGENCY CONTACT WHILE YOU ARE AT THE LABORATORY:

Name: Relationship:

Address, City State:

Phone: Alt. Phone:

TRANSCRIPTS

As part of the acceptance process you must also send your official transcripts to CSEE within 14 calendar days of the date of Offer Letter. Please mail official transcripts to:

CSEE

LBNL

One Cyclotron Road MS 7R0222

Berkeley, CA 94720

Attn: Transcripts

vLawrence Berkeley National LaboratoryvCenter for Science and Engineering Educationv

One Cyclotron RoadvMS7R0222vBerkeley, California 94720vTel: 510.486.5511vFax: 510.486.4813

csee.lbl.gov

Updated October 2011

TRAVEL TO/FROM LBNL

Typical travel dates are the Saturday prior to the start of the program and departing the Saturday after the program ends. You may choose alternate dates if you wish to arrive early or depart later.

Please note that you will not be permitted to start the program earlier than day of orientation.

If you elect to drive instead of fly, you will be reimbursed for actual mileage {based on standard highway guide (zip code to zip code) as long as it’s less than what the Lab would have paid for airfare.

______I’m driving to LBNL from farther than 50 miles. Please note: LBNL does not provide on-site parking privileges to participants. You will not be permitted to drive to the Lab for the internship.

______I am a SF Bay area resident and I live less than 50 miles from LBNL; I require no travel arrangements.

PREFERRED AIR TRAVEL REQUEST TO LBNL

LBNL Arrival Date (preferred):

LBNL Arrival Time (preferred):

Airport of Origin (preferred):

City of Origin (preferred):

Destination Airport (preferred):

Destination City (preferred):

Airline (preferred):

Flight Number (preferred):

ALTERNATE AIR TRAVEL REQUEST TO LBNL

LBNL Arrival Date (alternate):

LBNL Arrival Time (alternate):

Airport of Origin (alternate):

City of Origin (alternate):

Destination Airport (alternate):

Destination City (alternate):

Airline (alternate):

Flight Number (alternate):

PREFERRED RETURN AIR TRAVEL REQUEST

Return Date (preferred):

Return Time (preferred):

Airport of Origin (preferred):

City of Origin (preferred):

Destination Airport (preferred):

Destination City (preferred):

Airline (preferred):

Flight Number (preferred):

ALTERNATE RETURN AIR TRAVEL REQUEST

Return Date (alternate):

Return Time (alternate):

Airport of Origin (alternate):

City of Origin (alternate):

Destination Airport (alternate):

Destination City (alternate):

Airline (alternate):

Flight Number (alternate):

REQUIRED DEMOGRAPHIC INFORMATION

White (Not Hispanic or Latino)

Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East

Black or African American (Not Hispanic or Latino)

Persons having origins in any of the black racial groups of Africa

Asian (Not Hispanic or Latino)

Chinese/Chinese-American: Persons having origins in any of the original peoples of China

Japanese/Japanese-American: Persons having origins in any of the original peoples of Japan

Filipino: Persons having origins in any of the original peoples of the Philippine Islands

Pakistani/East Indian: Persons having origins in any of the original peoples of the Indian subcontinent (e.g., India and Pakistan)

Other Asian: Persons having origins in any of the original peoples of the Far East (Including Cambodia Korea, Malaysia, Thailand, and Vietnam) and Southeast Asia

American Indian or Alaskan Native (Not Hispanic or Latino): Persons having origins in any of the original peoples of North and South America, (including Central America) and who maintains tribal affiliation or community attachment

Native Hawaiian or other Pacific Islander (Not Hispanic or Latino): Persons having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands

Hispanic or Latino (Including Black individuals whose origins are Hispanic):

Mexican/Mexican-American/Chicano: Persons of Mexican culture or origin, regardless of race

Latin American/Latino: Persons of Latin American (e.g., Central America, South America, Cuban, Puerto Rico) culture or origin, regardless of race

Other Spanish/Spanish-American listed above: Persons of Spanish culture or origin, not included in any of the Hispanic categories listed above

Two or More Races/Ethnicities: Persons who identify with more than one of the above races/ethnicities.

Choose to not self-identify

Return this form electronically as a Word or PDF document to either

, , , or .

vLawrence Berkeley National LaboratoryvCenter for Science and Engineering Educationv

One Cyclotron RoadvMS7R0222vBerkeley, California 94720vTel: 510.486.5511vFax: 510.486.4813

csee.lbl.gov

Updated October 2011