First Name:
Last Name:
e-mail:	sample-applicant@example.com
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
Congressional District:	District 1 District 2 District 3 District 4 District 5 District 6 District 7 District 8 District 9 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 Travel Fellowship Program?

University:	At what Indiana Space Grant Consortium Affiliate university will you enrolled during the period of this award? Anderson University Ball State University Indiana State University Indiana University Indiana University/Purdue University Indianapolis Purdue Polytechnic Columbus Purdue University Purdue University Fort Wayne Purdue University Northwest Taylor University Trine University University of Southern Indiana Valparaiso University
Major:
Degree Objective:	MA MS Masters
Expected Date of Graduation:

Title of Conference:
Location of Conference:
Dates of Conference:
Registration Fee:
Estimated Travel Costs:
Other Related Costs:	(printing, displays, shipping, etc.)

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)

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

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

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.