Department of Chemistry SUMMER 2001 UNDERGRADUATE RESEARCHASSISTANTSHIPS RESEARCH EXPERIENCES for UNDERGRADUATE PROGRAM June 4

Department of Chemistry

SUMMER 2005 UNDERGRADUATE RESEARCH ASSISTANTSHIPS

RESEARCH EXPERIENCE for UNDERGRADUATES program

May 31 - August 6, 2005

APPLICATION FORM
(DEADLINE FOR RECEIPT OF APPLICATION: March 1, 2005)

Name (Last,First):_____________________________________________
Undergrad. Insitution:_________________________________________ Expected Graduation Date:_______________________
Major:_________________________________________________________ Prior Research Experience (Yes or No):__________
Campus Address:________________________________________________ Campus Phone, Daytime:__________________________
_______________________________________________________________ Campus Phone, Evening:__________________________
_______________________________________________________________ E-Mail Address:_________________________________
Permanent Address:_____________________________________________ Last Date on Campus:____________________________
_______________________________________________________________ Permanent Phone:_______________________________
_______________________________________________________________

PLEASE ENSURE YOUR EMAIL ADDRESS IS LEGIBLE TO ANY POSSIBLE READER; ILLEGIBLE ADDRESSES HAVE CAUSED NUMEROUS PROBLEMS IN PREVIOUS YEARS; PROBLEMS ARE ALSO CAUSED BY CONFUSION BETWEEN THE LETTER 'ell" and the numeral "one" and between capital "oh" and the numeral "zero". If your email address contains any such problematic characters, be sure to explicitly identify them

PREFERRED AREAS OF RESEARCH INTEREST (Select only one.)

____ Analytical Chemistry ____ Organic Chemistry
____ Biological Chemistry ____ Physical Chemistry
____ Inorganic Chemistry

REFERENCES: (Use the reference forms to request letters from two faculty members who best know your academic and research work. List these individuals here as well.)

Name: __________________________________________ Name: __________________________________________
Title: ________________________________________ Title: ________________________________________
Department: ___________________________________ Department: ___________________________________
Institution: ___________________________________ Institution: ___________________________________
Phone: ________________________________________ Phone: ________________________________________
E-Mail: _______________________________________ E-Mail: _______________________________________

I herby certify that all of the above information is correct and true.

Signature: ________________________________ Date ____________

I hereby grant the NSF-REU program permission to use the above information for statistical analysis purposes only, with the proviso that no personal information will be released to anyone besides those few, qualified researchers doing the statistical analysis and that these researchers will only report/publish aggregate statistics. Your willingness to participate in this statistical survey may help ensure the continued growth and vitality of this Federally sponsored program.

Signature: ________________________________ Date ____________

CENSUS QUESTIONS (note some, but not all, of these are optional):

Ethnicity (check one):
   _____ Hispanic/Latino
   _____ Not Hispanic/Latino
   _____ I choose to skip this question.

Race (check one)
   _____ American Indian or Alaskan Native
   _____ Asian American
   _____ African American
   _____ Native Hawaiian or Pacific Islander
   _____ White
   _____ I choose to skip this question.

Personal (Mandatory Information):
   _________________________Date of Birth
   _________________________Sex
   _________________________Citizenship
   _________Have a Green Card (non-USA citizens, only)?

Challenges (check one):
   _____ Auditory
   _____ Motor
   _____ Visual
   _____ Other (explain)
   _____I choose to skip this question

ADDITIONAL MATERIALS: (These must be submitted before an application can be reviewed.)

1) LIST OF ALL COURSES THAT YOU ARE TAKING THIS CURRENT SEMESTER/TERM.
2) STATEMENT OF ACADEMIC INTERESTS AND CAREER GOALS.
This statement should be typed, double-spaced, and 1-2 pages long. Include your intentions regarding post-baccalaureate programs (graduate school, medical school, MD-PhD program, or other). Also include details of any previous research experience, although prior research experience is not a pre-requisite for this program.
3) TWO LETTERS OF REFERENCE FROM ACADEMIC FACULTY.
To be sent from the two persons named above directly to the Program Director (forms are available on the web).
4) AN OFFICIAL TRANSCRIPT.
This should include Fall 2004 grades and may be enclosed or sent directly.

RECEIPT DEADLINE: March 1, 2004

Submit to:	Questions or Problems
Prof. Joseph J. Grabowski
REU Program Director	Contact Prof. Grabowski at:
Department of Chemistry	Phone: (412) 624-8632
University of Pittsburgh	Fax: (412) 624-8611
Pittsburgh, PA 15260	E-mail: joeg@pitt.edu

The University of Pittsburgh, as an educational institution and as an employer, values equality of opportunity, human dignity, and racial/ethnic and cultural diversity. Accordingly, the University prohibits and will not engage in discrimination or harassment on the basis of race, color, religion, national origin, ancestry, sex, age, marital status, familial status, sexual orientation, disability, or status as a disabled veteran or a veteran of the Vietnam era. Further, the University will continue to take affirmative steps to support and advance these values consistent with the University's mission. This policy applies to admissions, employment, access to and treatment in University programs. This is a commitment made by the University and is in accordance with federal, state, and/or local laws and regulations.

last updated: 21 December 2004

Name (Last,First):_____________________________________________

Undergrad. Insitution:_________________________________________	Expected Graduation Date:_______________________

Major:_________________________________________________________	Prior Research Experience (Yes or No):__________

Campus Address:________________________________________________	Campus Phone, Daytime:__________________________

_______________________________________________________________	Campus Phone, Evening:__________________________

_______________________________________________________________	E-Mail Address:_________________________________

Permanent Address:_____________________________________________	Last Date on Campus:____________________________

_______________________________________________________________	Permanent Phone:_______________________________

_______________________________________________________________

____ Analytical Chemistry	____ Organic Chemistry
____ Biological Chemistry	____ Physical Chemistry
____ Inorganic Chemistry

Name: __________________________________________	Name: __________________________________________
Title: ________________________________________	Title: ________________________________________
Department: ___________________________________	Department: ___________________________________
Institution: ___________________________________	Institution: ___________________________________
Phone: ________________________________________	Phone: ________________________________________
E-Mail: _______________________________________	E-Mail: _______________________________________