NASA Space Grant Fellowship
Application Cover Sheet

Application Deadline:  April 3, 2006                Notification: May 12, 2006

Please print and complete this application cover sheet and submit along with your application materials. 


Name:

Penn State ID Number:

Local address:

Local phone number:
Email:
Major and College (Indicate if this is an Intercollege Research Program) : 

Degree Sought:
Anticipated Date of Completion:
Department Chair:
Thesis Advisor:

Title of Research Project (if known): 

GPA:  

I certify that (initial each):
[Note: If any statement is not initialed, your application will not be considered.]
___ I am a citizen of the United States.
___ I am or will be a full-time graduate student during the academic years 2006-2007.
___ If awarded a PSGC Fellowship, I agree to provide PSGC information about my studies and/or employment on request beyond the term of the award. (This is part of a NASA requirement to track the long range effectiveness of the scholarship program.)

Signature_______________________________________ Date___________

Would you like to subscribe to our listserv to receive information about NASA-related opportunities?
   yes   no   (please circle)


The following questions are requested solely for statistical purposes.  Provision of this information is optional. 

Please indicate your predominant racial/ethnic background: 
Native American (Indian)___     Alaskan Native___ 
White American (not Hispanic)___  Puerto Rican___ 
Hispanic American (not Puerto Rican)___    Pacific Islander (specify)___________    African American (not Hispanic)__ 
Asian American ___  Other (specify) ________________ 

Gender:  Male____    Female_____ 
Student with disability(specify)______________________
 

Please submit an original and three copies of all application materials to:
Jeanine Emigh
The Pennsylvania Space Grant Consortium
Penn State University
2217 Earth-Engineering Sciences Building
University Park, PA  16802
Tel: (814) 865-2535



Go to the Pennsylvania Space Grant Consortium Home Page
Go to The Pennsylvania State University Home Page