Fillable MINORITY PARTICIPATION PROGRAM (CSU-LSAMP) (California State University, Fullerton)

Fill Online, Printable, Fillable, Blank MINORITY PARTICIPATION PROGRAM (CSU-LSAMP) (California State University, Fullerton) Form

Use Fill to complete blank online CALIFORNIA STATE UNIVERSITY, FULLERTON pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MINORITY PARTICIPATION PROGRAM (CSU-LSAMP) (California State University, Fullerton)

On average this form takes 22 minutes to complete

The MINORITY PARTICIPATION PROGRAM (CSU-LSAMP) (California State University, Fullerton) form is 3 pages long and contains:

  • 0 signatures
  • 21 check-boxes
  • 77 other fields

Country of origin: US
File type: PDF

U.S.A. forms for California State University, Fullerton

BROWSE CALIFORNIA STATE UNIVERSITY, FULLERTON FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, (NSF Grant #1826490)
and the California State University’s Office of the Chancellor.
1
CAMPUS: FULLERTON
Initiated in 1993-1994, CSU-LSAMP is an alliance of the 23 campuses of the California State University (CSU) system which
supports a coordinated and comprehensive system-wide approach to broadening participation in science, technology,
engineering and mathematics (STEM) disciplines. Each of the CSU campuses has a CSU-LSAMP program that offers an array
of activities and services designed to improve retention and graduation of undergraduate students in STEM. In addition,
CSU-LSAMP seeks to increase the number of CSU-LSAMP students who enter STEM graduate programs.
To be eligible to participate in CSU-LS
AMP, students must:
•
Be a U.S. Citizen or Permanent Resident.
• Be enrolled at a participating campus in an undergraduate major in a
STEM discipline or have expressed an interest in pursuing a STEM
baccalaureate degree.
• Be an individual who has faced or faces social, educational, or economic
barriers to careers in STEM.
• Each individual CSU-LSAMP campus program may have additional
eligibility requirements.
I. GENERAL INFORMATION
Applying to be a: Participant Research Scholar: a letter of support is required.
Note: Participant applications accepted year-round. Research scholar applications accepted between August 20 and September 16.
Name:
Last First Middle
Address:
Street City Zip Code
CWID: ______________ Telephone: _____ CSUF Email: _ ____________
Date of Birth: Place of Birth:
City, State, & Country
Citizenship: U.S. Citizen Permanent Resident
If applicable, Permanent Resident Registration #:
Please mark one of the boxes provided for both “Ethnicity” and “Race.”
Ethnicity (for statistical purposes only): Hispanic or Latino (A person of Mexican, Puerto Rican, Cuban, Central or
South American, or other Spanish culture or origin, regardless of race)
Not Hispanic or Latino Decline to State
Race (for statistical purposes only):
Black or African-American - A person having
origins in any of the black racial groups in Africa
Native Hawaiian or Other Pacific Islander
- A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, Polynesia, Micronesia, or other
Pacific Islands
American Indian - A person having origins in any
of the original peoples of North America and maintaining
cultural identification through tribal affiliation or community
recognition
Alaska Native - A person having origins in any of
the original peoples of Alaska, including Eskimos or Aleuts
Asian - A person having origins in any of the original peoples
of East Asia, Southeast Asia, or the Indian subcontinent. This area
includes, for example, China, India, Indonesia, Japan, Korea, and
Vietnam
White - A person having origins in any of the original
peoples of Europe, North Africa, or the Middle East
Other (specify):
Decline to State
Gender:
Male
Female
Decline
to State
C
ALIFORNIA
S
TATE
U
NIVERSITY
L
OUIS
S
TOKES
A
LLIANCE FOR
MINORITY PARTICIPATION PROGRAM (CSU-LSAMP)
APPLICATION
Name of Applicant:
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, (NSF Grant #1826490)
and the California State University’s Office of the Chancellor.
1
II. PERSONAL INFORMATION
A. Please indicate your parents’ level of education:
Mother: No College Some College College Graduate Graduate School
Father: No College Some College College Graduate Graduate School
B. Disability Status (again, for statistical purposes only): Please check “yes” if any of the disabilities
listed below the check box apply to you. Otherwise, check no or decline to state.
Yes No Decline to State
• Deaf or serious difficulty hearing
• Blind or serious difficulty seeing even when wearin
g
gl
asses
• Serious difficulty walking or climbing stairs
• Other serious disability related to a physical, mental,
or emotional condition
C. Are you a veteran of the U.S. Armed Forces? Yes No Decline to State
D. The University designates you ELIGIBLE for need-based financial aid (ex. Pell grant)? Yes No
E. Are you treated as an independent student for financial aid purposes? Yes No
F. What is your Personal yearly income?
Less than $10,000 $10,001 - $20,000 $20,001 - $30,000 More than $30,000
G. What is your Family’s yearly income?
Less than $10,000 $10,001 - $20,000 $20,001 - $30,000 More than $30,000
III. EDUCATIONAL INFORMATION
Major: Minor (if any):
Class Level: (e.g. freshman, sophomore, junior, senior)
Total Number of Units Completed: _ _____ Semester ____ Quarter____
Total Number of Major Units Completed: ___ Semester ____ Quarter ____
G.P.A. (Do not round up):
Cumulative GPA GPA in Major
Date you expect to receive your CSU Undergraduate Degree:
Anticipated Undergraduate Degree (BA/BS):
Did you transfer from a California Community College? Yes No
If yes, which college:
If yes, how many units did you complete prior to transferring?
Did you complete an Associate’s degree? Yes No
Do you plan on pursuing a graduate degree (MS or PhD) after Cal State Fullerton? Yes No
Not including grants from the Financial Aid Office, will you or do you currently receive funding from any
other on-campus program such as McNair, MARC, Project RAISE, etc.?
Yes No
If yes, please indicate the program name, funding amount, and semesters of expected funding:
____________________________________________________________________________________
Name of Applicant:
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, (NSF Grant #1826490)
and the California State University’s Office of the Chancellor.
2
IV. Student Signature/Release
Please read the statement below and sign where indicated:
The information I have submitted in my California State University LSAMPS Application is true and accurate to
the best of my knowledge. I understand that to track the progress of the 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 study student transfer, retention, progression, and
graduation. 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 Statewide Office at California State University, Sacramento and each of the 23 affiliated Alliance
CSU campuses.
I authorize release and use of personal information, as described above, to the CSU-LSAMP program. I
understand that this information is to be used solely for evaluating the impact and effectiveness of the CSU-
LSAMP program and that individual student data will not be released to parties other than those directly
involved with the program.
I have read and understand all of the statements above.
Printed Name of Applicant:
Signature of Applicant: Date:
Once you complete the application, please request a zoom meeting with Dr. Ibragimov by sending an
email to lsamp@fullerton.edu
Your application and all the necessary paperwork will be proccessed
during the zoom meeting.
Additional Materials Needed for Research Scholar Application
A letter of support from a faculty member or research mentor at CSUF. Letters of support must be
emailed directly to LSAMP@fullerton.edu
by faculty mentors. The letter of support is only required for
Research Scholar applicants. For those individuals who are requesting a letter from their faculty research
mentor, please feel free to provide him or her with the
Letter Writer Guide .
Campus Coordinator Approval and Certification
The above named student is approved as a CSU-LSAMP student.
Yes – Is an individual who has faced or faces (check one) social educational economic
barriers to careers in STEM.
No – Does not meet eligibility criteria.
Printed Name of Campus Coordinator: Dr. Zair Ibragimov
Signature of Campus Coordinator: Date:
Student Acknowledgement – TO BE SIGNED BY STUDENT UPON APPROVAL TO PROGRAM
I understand that I have been accepted to the CSU-LSAMP Program and granted access to the
various activities therein. I further understand that I must maintain expectations explained to
me by the CSU-LSAMP Campus Coordinator for continued involvement in the program.
Signature of Applicant: _________________________ Date:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MINORITY PARTICIPATION PROGRAM (CSU-LSAMP) (California State University, Fullerton)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 September 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document