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Full"Name:"
Date:"
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Last%
First%
M.I.
Address:"
Apartment/Unit%#%
City%
State%
ZIP%Code%
Email:"
Are"you"a"U.S."citizen"or"Permanent"Resident?"
YES"
NO"
Sex"(optional"information):"
Male"
Female"
Other"
Ethnicity"(optional"information):"
Hispanic"or"Latino"
Black"or"African"American"
Asian"
Native"Hawaiian"or"Other"Pacific"Islander"
White"
Other"
American"Indian"or"Alaskan"Native"
9763"+$&()
Highest"Degree"Earned:"
Date"Earned:"
!
Institution:"
Location:"
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Math"courses"taken"(if"any)"after"undergraduate"degree:"
9@;#&0@,(+)
School"that"you"are"teaching"at:"
Location"(City,"State):"
2"
What"math"courses"are"you"teaching"and"have"you"taught?"
What"professional"activities"have"you"been"involved"in"(e.g.,"conference"attendance/presentation,"
supervising"mathem atical"com petitions"or"other"extracurricular"even ts,"professional"developm en t"
experiences)?""
A,++,')&%)*6;;&'+)B&;+$&("#C)
You"are"encouraged,"but"not"required,"to"provide"a"letter"of"support"from"an"administrator"(e.g.,"a"
principal)."Please"have"your"reference"send"his/her"letter"to"the"e-mail"or"mailing"address"listed"at"the"end"
of"this"form."
Administrator"Name:"
Job"Title:"
!
School:"
e-mail:
9//"0)D6,/+$&(/)
Please"respond"to"both"of"the"following"questions."Each"response"should"be"500"words"or"less."
1. Why"are"you"interested"in"this"program?"What"are"your"mathematical"interests?
2. What is the deepest, most exciting, or most interesting mathematical result or application that
you’ve ever learned about? What do you find compelling about it?
*6E@$//$&()
Application"checklist:"
1. Application"form
2. Answers"to"essay"questions"(please"answer"both)
3. Letter"of"support"(Optional,"but"encouraged."Please"have"it"sent"directly"from"your"administrator.)
All"of"the"required"materials"should"be"e-mailed"to:"
Prof."Sergei Fomin
sfomin@csuchico.edu"
After"filling"out"your"application"form,"scan"it"and"save"it"as"a"pdf."Your"letter"of"support"should"be"
sent"directly"from"your"administrator."
If"e-mail"is"not"possible"for"any"of"the"items"mentioned"above,"please"have"those"materials"mailed"to:"
Prof."Sergei Fomin""
Department"of"Mathematics"&"Statistics"
California"State"University,"Chico""
Chico"CA"95929-0525"
Signature:"
Date:"
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