First Name:
Last Name:
e-mail:	sample-applicant@example.com
Alternate e-mail:
Current Address:
	, 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
Cell Phone:	( ) -
Permanent Address:
	, 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
Birthdate:

University:	Choose the Delaware Space Grant Consortium institution you will attend in the fall: Delaware State University Delaware Technical and Community College - Owens Campus Delaware Technical and Community College - Stanton Campus Delaware Technical and Community College - Terry Campus Delaware Technical and Community College - Wilmington Campus Swarthmore College University of Delaware Villanova University Wilmington University
Major:
September 2024 University Standing:	Freshman Sophomore Junior Senior As of September 2024
Educational History:	List the universities that you have attended beginning with the most recent. Only list universities where you have completed at least 10 credit hours. Please upload a PDF version of your transcript. If you are selected to receive the award, official transcripts may be required for verification. If you do not have a PDF conversion tool you can use one of these free on-line PDF converters: PDF Online - PDF Converter. To ensure that your PDF files may be properly included in your application, please ensure that they are not protected via encryption, a password, a signed certificate, or in any other manner.
College/University Major Credits Completed Transcript File Upload File Upload File Upload File Upload

A letter of recommendation from Department Chairperson, DESGC Consortium Representative and/or Advisor.

Name:
Title:
Institution:
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. A statement from applicant describing completed academic work and career plans indicating how these relate to NASA's mission to drive advances in science, technology, and exploration to enhance knowledge, education, innovation, economic vitality, and stewardship of earth. (Limited to 600 words)
The following information is for reporting purposes only.

Gender:	Male Female Do not wish to report
Ethnicity:	Hispanic or Latino Not Hispanic or Latino Do not wish to report
Race:	American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Do not wish to report
Disability:	I do not have a disability I do not wish to identify my disability status Vision Hearing Paralysis Missing Extremities Other Impairments I have a disability, but it is not listed   Specify if not listed:
	How did you hear about the NASA Delaware Space Grant Undergraduate Tuition Award?
Person With Disability:	Yes No Undisclosed

		I am a citizen of the United States of America
		I understand that an award in this program is contingent upon the applicant's acceptance into a STEM-related undergraduate program at a Delaware Space Grant member institution.
		I certify that all of the information contained in this application is complete and correct and that I meet all of the eligibility requirements for this program.