First Name:
Last Name:
e-mail:	sample-applicant@example.com
Address:
City:
State:	AK AL AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip:
Phone:	-
Curriculum Vitae/Resume:	File Upload (PDF format only)

College:	What Arkansas Space Grant College will you be attending in the Fall? Arkansas Northeastern College Arkansas State University Mid-South Southern Arkansas University Tech University of Arkansas Pulaski Tech
Department:
Current College Standing:	Freshman Sophomore
Major:
GPA:	(4 Point Scale)
Credit Hours:
College ID:
Transcript (Unofficial or Official):	File Upload

What is the highest degree you would like to attain in the future? Bachelors Masters Doctorate
What would be your probable field of study for this degree? Aeronautical/Aerospace Agricultural Anthropology Architectural Architecture Art Astronomy Astrophysics Atmospheric Science Biochemistry Bioengineering Biology Botany Chemical Chemistry Civil Climatology/Meteorology Computer Computer Science Earth Sciences Economics Education Electrical/Electronic Engineering Engineering Mechanics Engineering Science Environmental Environmental Science Geography Geology Geophysics Health Science/Nutrition History Industrial Life Sciences Materials Science/Engineering Mathematics Mechanical Medicine/Medical Research Mining/Petroleum & Natural Gas Molecular/Cell Biology Nuclear Oceanography Other Philosophy Physical Sciences Physics Planetary GeoSciences Planetary Sciences Political Science/Public Policy Psychology Social Sciences Sociology Zoology
After completing your studies, where do you plan to work? Private Industry Teaching (K-12) NASA Non-NASA Federal Agency State/Local Government Nonprofit Organization Military Consulting Undecided Other Please describe your academic and career goals.
(200 words or less.)
How will this award opportunity impact you personally and professionally?
(200 words or less.)

	Campus Representative Title: Name: Institution: Department: Phone: email: email confirm: Faculty Advisor Title: Name: Institution: Department: Phone: email: email confirm:
	Once you have submitted your application we will email them instructions on how to submit an on-line letter of recommendation on your behalf. Please inform them that they will be receiving an email from notices@spacegrant.net with these instructions. Letters of recommendation are due by Thursday, October 6, 2022.

Gender:	Male Female
Birthdate:
Ethnicity:	Hispanic or Latino Not Hispanic or Latino
Race:	American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other
Disability:	I do not have a disability I do not wish to identify my disability status Vision Missing Extremities Other Impairments I have a disability, but it is not listed   Specify if not listed:
U.S. Citizenship:	I am a citizen of the United States of America. Yes No
First Generation:	Will you or your siblings be the first in your family to graduate from college? Yes No
Military Service:	Have you ever served in the U.S. military? Yes No

Photo Release:	File Upload (PDF format) By uploading this file, you give NASA and the Arkansas Space Grant Consortium permission to use your photos on the website, in marketing tools, and other public forums. The form can be accessed at https://www.nasa.gov/sites/default/files/files/NASA_Adult_Media_Release_Form.pdf.
	I am a citizen of the United States of America
	I am a full time student at an member institution
	If awarded, I agree to provide , or its agents, information about my studies and/or employment on request beyond the term of the award (this is part of a NASA requirement to track long range effectiveness of the program)
	I certify that all of the information contained in this application is complete and correct and that I meet all of the eligibility requirements stated in this application.