Southern University and A & M College

P. O. Box 11776 - Baton Rouge, LA 70813

Phone: (225) 771-2730 Fax: (225) 771-4341

e-mail:

PERSONAL DATA
Name (last, first, middle): / Social Security No.:
E-mail Address (Important): / Date of Birth:
Mailing Address:
City: / State: / Zip Code:
Home Phone: / ( ) / *Specify Gender: / Male Female
Permanent Address (if different from above)
City / State / Zip Code
Permanent Contact Phone Number / ( )
*Ethnicity (Check all that apply.): / African American / Asian American / Hispanic American
Native American / White American/Caucasian / Other ______
*This optional information has no bearing on the selection process. It is strictly for statistical purposes.
Citizenship / U. S. / Permanent Resident / Other
(U.S. citizenship is required for program components supported by federal funds)
EDUCATION RECORD
High School : / Expected Graduation Date: / GPA:
(ATTACH A COPY OF AN OFFICIAL TRANSCRIPTS HIGH SCHOOL & COLLEGE, IF APPLICABLE)
High School Classification / q 10th / q 11th . q 12th .
PARENT/GUARDIAN INFORMATION
MOTHER
Name / Address (if different from above) / Daytime Phone Number
FATHER
Name / Address (if different from above) / Daytime Phone Number
Highest grade completed by / MOTHER / FATHER
ACT SCORES: Composite: ______
English: ______Math: ______
Reading: ______Sci. Reas. _____
SAT: Verbal ______Math ______/ MAIL COMPLETED APPLICATIONS TO:
Dr. Diola Bagayoko
Director, Timbuktu Academy
P. O. Box 11776
Baton Rouge, LA 70813 / FOR OFFICE USE ONLY:
Date Received: ______
Status: ______
Letter:______
APPLICATION DEADLINE: One week after the receipt of the form, rolling admission thereafter
Student's Signature / Parent's Signature (if applicant under 18 years of age)
Date / Date
APPLICATIONS ARE DEEMED INCOMPLETE UNLESS ACCOMPANIED BY A SHORT ESSAY, TWO LETTERS OF RECOMMENDATION, ACT/SAT SCORE REPORT,A RESUME AND AN OFFICIAL HIGH SCHOOL TRANSCRIPT.

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Challenge 2000 Application Form /

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REFERENCES
Please list below the name, title/affiliation, and office phone number of the two (2) individuals you have asked to write a letter of recommendation. NOTE: INDIVIDUALS MUST BE HIGH SCHOOL SCIENCE, ENGLISH, MATHEMATICS, OR ENGINEERING TEACHERS/INSTRUCTORS OR COUNSELORS.
Name / Title / Telephone
Name / Title / Telephone
Name / Title / Telephone

ESSAY

On a separate sheet, please describe your career goals, interest in science, and previous science experiences (science fairs/rallies, summer research, summer enrichment, etc., if any.
CHECK LIST
This application must have the following documents attached:
1.  Official high school/college transcript(s)
2.  Two letters of recommendation
3.  Essay (See Section Above)
4.  ACT/SAT score report (all pages)
5.  Resume' (See sample resume' at our website http://www.phys.subr.edu/timbuktu.htm)
APPLICATION DEADLINE: One week after the receipt of the application form, rolling admission thereafter
The application form and addition information on the Timbuktu Academy may also be obtained via the home page of the Timbuktu Academy:
http://www.phys.subr.edu/timbuktu.htm
APPLICATIONS ARE DEEMED INCOMPLETE UNLESS ACCOMPANIED BY AN ESSAY, TWO LETTERS OF RECOMMENDATION, THE ACT/SAT SCORE REPORT, A RESUME, AND THE APPLICABLE TRANSCRIPT(S).

THE TIMBUKTU ACADEMY IS FUNDED IN PART BY THE DEPARTMENT OF THE NAVY, OFFICE OF NAVAL RESEARCH (ONR), THE NATIONAL SCIENCE FOUNDATION (NSF), NASA , NIST, AND THE HEWLETT PACKARD (HP) COMPANY

The Director of the Timbuktu Academy won the individual US Presidential Award for Excellence in Science, Mathematics, and Engineering Mentoring in 1996. Honorable President William Jefferson Clinton signed this award.

The Timbuktu Academy received the 2002 US Presidential Award for Excellence in Science, Mathematics, and Engineering Mentoring. Honorable President George W. Bush signed this award which, unlike the previous one, is for the program.