California State University
Louis Stokes Alliance for Minority Participation
(CSU-LSAMP)
Eligibility:
· Have US Citizenship or permanent resident status
· Science, Technology, Engineering or Math (STEM) major at California State University, Fresno
· Be an individual who has faced or faces social, educational, or economic barriers to careers in STEM.
Funded By:
The National Science Foundation (NSF) under grant #HRD-1302873, the Chancellor's Office of the California State University, and California State University, Fresno.
PERSONAL INFORMATION
Name Campus Student ID #
Last First MI
Residency Status
Gender Male Female US Citizen Permanent Resident Social Security #
If applicable, Permanent Resident Registration#:
CONTACT INFORMATION
Mailing Address Street Apt # City Zip
Home Phone ( ) - Cell Phone ( ) -
Campus Email ______Alternate Email ______
Check here if Address 2 is same as above
Permanent address
Street Apt # City State Zip
PERSONAL AND FAMILY BACKGROUND
Parents’ marital status: Married Divorced/Single Parent Legally Separated Widowed
Mother: Living Deceased Occupation______Highest Educational Level (Please check box)
Elementary (K-6) High School Community College University Degree earned in College / University? No If Yes, Type ______
Father: ___ Living ____ Deceased Occupation______Highest Educational Level (Please check box)
Elementary (K-6) High School Community College University Degree earned in College / University? No If Yes, Type ______
Please describe any disabilities you may have:
As an undergraduate, are you eligible for need-based financial aid? Yes No
Are you treated as an independent student for financial aid purposes?
$38,701-45,220
$45,221-51,740
$49,741-58,260
$58,261- +
Yes No
$38,701-45,220
$45,221-51,740
$49,741-58,260
$58,261-+
$0-19,140
$19,141-25,660
$25,661-32,180
$32,181-38,700
$0-19,140
$19,141-25,660
$25,661-32,180
$32,181-38,700
Household Size: # Adults ______# Children ______
Ethnicity - Please select
Alaska Native African American/Black Hispanic/Latino Native American (Specify nation):
Native Hawaiian or Pacific Islander (Specify): Bicultural (Specify):
Other (Specify): ______What is the primary language spoken in your home?
ACADEMIC BACKGROUND
Please check what applies to you:
High school senior or recent high school graduate
High School currently attending or recently graduated: GPA:
Academic Background Continued:
Community College student - I am transferring to Fresno State in 20 (circle) Fall or Spring semester
Community College attending or recently attended GPA:
Fresno State student - GPA: Other (please explain):
Please indicate which of the following tests you have taken:
- ELM Score EPT Score SAT: Verbal Math ACT: Verbal Math
List the highest level you have taken in the following subjects and grades received
Course Name (Example: Calculus, Biology etc.) Grade Received
Biology
Chemistry
English
Math
Physics
Other Science
ACTIVITIES/HONORS
List any extracurricular activities in which you have participated while attending school (indicate whether high school, community college or university level).
Do you work? ______If yes, average number of hours per week: ______
List any honors/awards you have received while attending school (indicate whether high school, community college or university level).
Please indicate past or current participation in any other student support program(s):
Metro Talent Search Upward Bound EOP
CAMP/UMS MEP/MESA McNair RISE Other:
ACADEMIC AND CAREER GOALS
Please indicate your expected or current college major.
- Agricultural Science
- Biology Geomatics Engineering
- Chemistry Industrial Engineering
- Civil Engineering Mathematics
- Computer Science Mechanical Engineering
- Computer Engineering Natural Science
- Earth & Environmental Science Physics
Electrical Engineering Other (specify):
Career Objective: (e.g. Master’s, Phd, and specify area/field)
PERSONAL STATEMENT (PLEASE TYPE)
In the space below or on a separate sheet of paper, please answer the following questions
A) Describe the social, educational or economic barriers you have had to overcome in order to pursue a science, technology, engineering or math (STEM) major/career.
B) Why are you interested in a STEM career?
The information I have submitted in my CSU-LSAMP Program Application is true and accurate to the best of my knowledge. I understand that to track the progress of CSU-LSAMP students and to evaluate program effectiveness, CSU-LSAMP requires access to student information. The CSU-LSAMP program is required to report individual student data to the National Science Foundation including social security number, ethnicity, GPA, and enrollment status. This information is also used to access information on the National Student Clearinghouse, study student transfer, retention, graduation, and progression to graduate study. Photographs and research abstracts may also be obtained for use by the CSU-LSAMP program in program dissemination materials such as websites, newsletters, and reports. The student data are collected by the CSU-LSAMP California State University, Fresno (Fresno State) and Statewide Office at California State University, Sacramento. I am aware of the provisions of the Family Educational Rights and Privacy act and hereby authorize the release of the requested information directly to California State University, Fresno CSU-LSAMP (i.e. transcripts, letters of recommendation, etc.).
Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and do not reflect the views of the National Science Foundation.
Student Signature Print Name Date
PLEASE MAIL YOUR APPLICATION AND TRANSCRIPTS (UNOFFICIAL ACCEPTED) TO:
California State University, Fresno
LSAMP Program
2555 E. San Ramon Ave M/S SB68
Fresno, CA 93740-8034
Note: You may also drop off application in Science building #100
For more information about CSU-LSAMP call (559) 278-4748 (278-7804 fax), visit us online at www.csufresno.edu/lsamp or contact