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Application Form for Undergraduate Students

I. PERSONAL INFORMATION
Last Name:
 First Name:
 Middle Initial:

Current Address:

City:

 State: (xx)
 Zip Code:
Primary Phone: ( xxx-xxx-xxxx ) Secondary Phone: ( xxx-xxx-xxxx ) Email:

II. PERSONAL INFORMATION
Ethnicity: (Choose one response) Hispanic or Latino Not Hispanic or Latino
Race: (Select one or more)

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

White

Black or African American

Asian

Disability Status: (Select one or more)

Hearing Impairment

Visual Impairment

Mobility/Orthopedic Impairment

None

Check here if you do not wish to provide any or all of the above information

II. EDUCATION
High School: Date of Graduation: (xx/xxxx)
College:
Expected Date of Graduation: (xx/xxxx)
Major:
GPA in Science Courses:
List all college science courses you have completed and those in which you are currently enrolled.
Course Name
Date Taken (Semester/Year)
Grade Received

III. POSTDOC SELECTION
The following postdocs will be participating in the PERT Research Opportunity. Please select three choices, in order of preference.
  FIRST CHOICE   SECOND CHOICE   THIRD CHOICE
  Toby Daly-Engel   Toby Daly-Engel   Toby Daly-Engel
  Matina Donaldson-Matasci   Matina Donaldson-Matasci   Matina Donaldson-Matasci
  Aimee Dunlap-Lehtila   Aimee Dunlap-Lehtila   Aimee Dunlap-Lehtila
  Jeff Eble   Jeff Eble   Jeff Eble
  Dorit Eliyahu   Dorit Eliyahu   Dorit Eliyahu
  Kim Franklin   Kim Franklin   Kim Franklin
  Dawn Higginson   Dawn Higginson   Dawn Higginson
  Jennifer Koop   Jennifer Koop   Jennifer Koop
  Richard (Rick) Lapoint   Richard (Rick) Lapoint   Richard (Rick) Lapoint
  Wallace (Marty) Meyer   Wallace (Marty) Meyer   Wallace (Marty) Meyer
  Nicole Rafferty   Nicole Rafferty   Nicole Rafferty
  Richard Smrt   Richard Smrt   Richard Smrt
  Matthew Stansbury   Matthew Stansbury   Matthew Stansbury
  Lana Vojvodic   Lana Vojvodic   Lana Vojvodic
  NO PREFERENCE   NO PREFERENCE   NO PREFERENCE

IV. REFERENCE

Please provide the name, address, telephone number and email address of an instructor from whom you have taken a college science course in the last two years:
Name of Instructor:
 Work Address:
Telephone Number:
Email Address:

V. CERTIFICATION

I certify that all information supplied by me in this application is accurate and complete and that any misrepresentation on this application will be cause to nullify my application. I also agree to abide by the rules and regulations of Pima Community College (if applicable) and the University of Arizona.
I Agree