UNC Charlotte / PRODUCE Program
NC-LSAMP Bridge to the Doctorate Scholarship Application
PLEASE TYPE OR PRINT CLEARLY
NAME______________________________________________________________________________
LAST FIRST MIDDLE
SOCIAL SECURITY NUMBER: _____________ - ______________ - _________________
PERMANENT ADDRESS: LOCAL ADDRESS:
_____________________________ _____________________________
_____________________________ _____________________________
_____________________________ ______________________________
TELEPHONE: ( )________________________ E-MAIL ______________________
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BACKGROUND INFORMATION:
DATE OF BIRTH _______________ PLACE OF BIRTH _______________________________
RACE: African American ___ Hispanic ___ Native American ___ Alaskan Native ___ Asian___
Pacific Islander ___ Other (Please List) ____________________
GENDER: Male ___ Female ___ Citizenship: U. S. Citizen ___ Permanent Resident ___
DISABILITY STATUS: Hearing Impaired ___ Visually Impaired ___ Mobility Impaired ____ N/A _____
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ACADEMIC INFORMATION:
UNDERGRADUATE PROGRAM
COLLEGE/UNIVERSITY _____________________________________________________________
MAJOR ___________________________________ MINOR ____________________________
DATE OF GRADUATION ____________/__________ DEGREE EARNED: (circle one) BA BS
GPA _____________________
GRADUATE PROGRAM
GRADUATE DEPARTMENT APPLIED OR ACCEPTED TO: _________________________________________
CONCENTRATION WITHIN DEPARTMENT: ____________________________________________________
DEGREE SOUGHT: (circle one) M.S. M.A.
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RESEARCH / INTERNSHIPS / WORK EXPERIENCE: Please list your most recent research, internship and/or work experience. Attach separate sheet if necessary.
COMPANY/INSTITUTION TYPE OF WORK FROM/ TO SUPERVISOR/MENTOR
____________________ ____________________ ___________ ________________
____________________ ____________________ ___________ ________________
____________________ ____________________ ___________ ________________
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FULL-TIME STATUS
Bridge Scholars must be registered as full-time students (9 credit hours of graduate course work) and are strongly advised to refrain from having a full-time job during their tenure in the Bridge to the Doctorate Program. By signing below, you acknowledge that you understand these policies and agree to abide by them if accepted as a Bridge Scholar.
_________________________________________ _______________________________________ SIGNATURE DATE
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STATEMENT OF INTEREST
Please enclose a one-page statement detailing your interest in pursuing a graduate degree in a STEM field, the ways you expect your involvement in the Bridge to the Doctorate Program will benefit you, and the ways in which you expect you involvement to impact the advancement of underrepresented minorities in the STEM professions, and academia.
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CERTIFICATION/ PARTICIPANT AGREEMENT
I certify that the information provided by me is true and correct to the best of my knowledge. I also understand that by signing my name below, I authorize the release of transcripts and financial aid records from all institutions I have attended or will attend while participating in the NC-LSAMP Bridge to the Doctorate program.
I further agree to comply with all requirements stipulated for recipients of an NC-LSAMP Scholarship and stipend support for Bridge Scholars, and that failure to remain in full compliance with this agreement disqualifies me for future Alliance awards. In addition, I understand that such awards are considered scholarships for financial purposes and may reduce my financial aid award.
I also give authorization for program staff to review materials or obtain copies of information including transcripts and letters of recommendation pertaining to my application from the UNC Charlotte Graduate School.
______________________________________ __________________________
Signature of Applicant Date
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