PERSONAL INFORMATION
Name (Last, First, M.I.):
Social Security Number:
Date of Birth:
	Male   Female
Address:
Tel - Day:
Tel - Evening:
E-mail:
WORK HISTORY
Name and address of school at which you are currently teaching:
Courses:
Name of principal:
Telephone No.:
Number of years at the school:
Previous work experience (please list teaching appointments chronologically):
Name and Address of School:
Name of principal:
Telephone No.:
Years of Employment:	from to
Name and Address of School:
Name of principal:
Telephone No.:
Years of Employment:	from to
ACADEMIC HISTORY
Name & location of colleges/universities attended:
Degree(s):
Year of conferral of degree(s):
Major(s):
Honors and awards:
GENERAL INFORMATION
Have you previously participated in an internship program at TSRI?    Yes (Year: )   No
If yes, name of principal investigator:
Area of Research:
Have you participated in a research internship program at another institution?    Yes   No
If yes, name of institution:
Investigator with whom you worked and area of research:
Year:
Length of internship program:
Funding source:
Additional teacher training, seminars attended, university-affiliated internships:
Do you work in a school that has a high percentage of students who belong to ethnic minority groups who are considered underrepresented in the sciences?   Yes   No
Your Ethnicity:   African American   Native American   Caucasian   Native Pacific Islander   Asian   Hispanic   Other   Decline to state
PERSONAL STATEMENT Please include below, or mail a one-page statement outlining your reasons for applying for the program, goals you hope to accomplish, and any information which may assist the selection process.