Indiana Space Grant Consortium Application System

Please Note: This is a sample application for viewing purposes only. To apply to this program please visit the application "New User Registration" page and register with the system.

Personal Information

First Name:
Last Name:
e-mail:	sample-applicant@example.com
Current Address:
	,
Congressional District:	To find your Congressional District visit the House of Representatives Website.
	If your permanent home address is out of state please choose the congressional district for your school.
	How did you hear about the INSGC STEM Education Major Fellowship Program?

Educational Information

University:	At what Indiana Space Grant Consortium Affiliate university will you enrolled during the period of this award?
Major:
Degree Objective:
Expected Date of Graduation:

STEM Teaching Statement of Work

Location of STEM Teaching Activity:
Date and Duration of STEM Teaching Activity:
Age of Students/Type:	(5th grade science class, museum program for general public, etc.)
Projected Number of Students:
STEM Teaching Activity Budget:	Supplies needed and budget including costshare (300 words or less)

Other Information

Resume:	File Upload (PDF format)
Career Goals:	What are your short and long term career objectives (5 and 20 years)? (300 words or less)
Honors and Societies:	Please describe any honors or awards that you have received and any societies that you are a member (includes dates and position held). (300 words or less)
	Have you previously received any other Indiana Space Grant Consortium funding? Yes No If so please describe the program and your experience. (300 words or less)

NASA Alignment

Please indicate below how this work aligns with NASA's Mission Directorates

Aeronautics Research Mission Directorate Advanced Air Vehicles Airspace Operations and Safety Integrated Aviation Systems Transformative Aeronautics Concepts	Human Exploration & Operations Mission Directorate Human Research Space Life Science Physical Science Research Engineering Research
Science Mission Directorate Astrophysics Earth Science Heliophysics Planetary Science	Space Technology Mission Directorate Transformative Crosscutting Technologies Technology Research and Development Challenges

Please describe how your work is aligned with NASA's Mission Directorates
(500 words or less)
INSGC encourages students to experience NASA-related research and career opportunities first-hand at NASA Centers or industry visits. Are you interested in receiving additional funding for expenses related to visiting a NASA Center or relevant industry (amount dependent upon location)? Yes No

Optional Information

Students are strongly encouraged to provide the information requested below which is for reporting purposes only.

Ethnicity:
Race:
Birthdate:
Person With Disability:	Yes No
Are You a Veteran:	Yes No

Certification

I am a citizen of the United States of America

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.

Please Note: This is a sample application for viewing purposes only. To apply to this program please visit the application "New User Registration" page and register with the system.