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PERSONAL INFORMATION |
| Name (Last, First, M.I.): | |
| Date of Birth: | |
| | Male Female |
| Address: | |
| Tel - Day: | |
| Tel - Evening: | |
| E-mail: | |
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WORK HISTORY |
| Name and address of school at which you are currently teaching: |
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| Courses: | |
| Name of principal: | |
| Telephone No.: | |
| Number of years at the school: | |
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| Previous work experience (please list teaching appointments chronologically): |
| Name and Address of School: |
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| Name of principal: | |
| Telephone No.: | |
| Years of Employment: | from to |
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| Name and Address of School: |
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| Name of principal: | |
| Telephone No.: | |
| Years of Employment: | from to |
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ACADEMIC HISTORY |
| Name & location of colleges/universities attended: |
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| Degree(s): | |
| Year of conferral of degree(s): | |
| Major(s): | |
| Honors and awards: |
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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: |
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| Additional teacher training, seminars attended, university-affiliated internships: |
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| 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 |
TR>If hired, can you provide proof that you are a citizen or national of the United States of America, a lawful permanent resident, or an alien authorized to work in this country? | Yes No |
| If you hold a visa that authorizes you to work in the US, list visa type: | |
| Visa Expiration date: |
Your Ethnicity (optional):
- African American
- Native American
- Caucasian
- Native Pacific Islander
- Asian
- Hispanic
- Other
- Decline to state
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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. |
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