We
are pleased that you are participating in the More Graduate Education@Mountain States Alliance project. Your answers are used for MGE@MSA and federal
reporting purposes only and are completely confidential. Incomplete forms
will not be processed. If you have any questions call the MGE@MSA staff at (800) 327-4893.
Thank you.
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| University |
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| Name
of Mentor |
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1.
Student Information
|
| Name |
|
| Date
of Birth |
(e.g.
1978) |
| Social
Security |
|
|
| Gender |
|
Current
Address
(Street/Box)
|
|
| City |
|
| State |
|
| Zip |
|
This
address
effective until |
|
Current
Phone
Number |
|
Permanent
Address
(Street/Box)
|
|
| City |
|
| State |
|
Zip |
|
Permanent
Phone Number |
|
| E-mail |
|
|
|
|
Which
of the following best describes your ethnicity? (If you qualify for
more than
one category, please identify them as to which you most closely identify
with.)
Black/African American
Cuban American
Mexican American
Puerto Rican
Other U.S. Hispanic(Please
specify)
American Indian/Alaska Native |
| |
Enrolled
member of tribe, nation, or band
|
| |
(Please
specify tribal affilliation ) |
If
enrolled as a member of a tribe, nation, or band, please specify tribal
registration number:
|
|
American Indian/Alaska Native |
| |
Not Enrolled member of tribe, nation, or band
|
| |
(Please
specify tribal affilliation ) |
Hawaiian Native
Pacific Islander
|
| |
(Please
specify which
island) |
|
Other
|
| |
(Please
specify) |
Asian American
Anglo/White
Other Underrepresented
|
| |
(Please
specify) |
What
language was spoken most often at home while you were in elementary/
secondary school? |
|
|
Are
you a first generation college attendee (i.e. neither your parents, guardians
nor
grandparents attended college)?
|
Are
you premanently physically, mentally, or emotionally challenged and/or
permanently disabled? If yes, please specify from the following choices:
(Press control to select more than one option)
if
Other (Please specify)
|
2.
Current Degree Program
What
is your major field? |
|
|
|
What
is your area of specialization? |
|
What
specific degree are you currently pursuing? |
|
| When
did you begin your current degree program? |
|
| When
do you anticipate completing your current degree program? |
|
I
understand that only United States citizens or permanent residents of
the United States underrepresented
in mathematics, science and engineering (including advanced technology)
such as students of Hispanic, African American, American Indian, Alaska
Native or Pacific Islander origin are eligible for application under
this program. I hereby certify my eligible status
for the program as defined above. I certify that the information contained
in this biographical
form is complete and accurate and I understand that the submission of
inaccurate information
may be sufficient cause for denial of funding. |
|
YES |
|
|
