First Name:
Middle Name:
Last Name:
e-mail:	sample-applicant@example.com
Alternate e-mail:
Verification of US Citizenship:	I am a citizen of the United States of America
Local 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   - ZIP Code +4 Lookup
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   - ZIP Code +4 Lookup
Text messaging:	Send applications updates via text message
Cell Phone:
Alternate Phone:	( ) -
Birthdate:
Residency:	Oregon     Other

University:	What Oregon Space Grant University will you be attending in the Fall? Eastern Oregon University George Fox University Oregon Institute of Technology Oregon State University Pacific University Portland State University Southern Oregon University University of Oregon University of Portland Western Oregon University
Class Standing:	Masters Student PhD Student As of March 2022
Major:
Expected Date of Graduation:
Cumulative GPA:	(for all subjects, 4 point scale)
GPA within major:	(4 point scale)
Transcript:	(PDF Format) An unofficial transcript printed from the student account of the college or university website is acceptable. If you are selected to receive this award, official transcripts may be required for verification.

Prior Educational History:
List the universities that you have attended. Please upload a PDF version of all transcripts. 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	Degree	Date Awarded	GPA (4 pt scale)	Transcript
		AA AS BA BA BBA BS AB Bachelors MA MBA MS MSE Masters JD MD PhD Doctorate
		AA AS BA BBA BS AB Bachelors MA MBA MS MSE Masters JD MD PhD Doctorate
		AA AS BA BBA BS AB Bachelors MA MBA MS MSE Masters JD MD PhD Doctorate
		AA AS BA BBA BS AB Bachelors MA MBA MS MSE Masters JD MD PhD Doctorate

Student Resume:	A summary of your career and qualifications, including relevant employment, education, extra-curricular activities, and significant accomplishments. Resume should include current contact information including email, phone, and mailing address. (PDF Format)
Statement of Interest	A brief statement describing your interest in space science/aerospace and your desire to pursue a related career in a STEM field. Describe how receiving this fellowship would benefit you and contribute to your academic and career goals and objectives. (Limit: 500 words)
Research Proposal:	A statement of work written by the student in consultation with the faculty advisor that describes the key elements of the proposed research and what the student intends to accomplish. Clearly describe the research objective and methodology and include a timeline. Identify how the proposed research relates to NASA's top research priorities and has strong alignment with NASA Mission Directorates (refer to Appendix A. Agency Information and Strategic Framework and Appendix B. Research Priorities for NASA Mission Directorates). (Limit: 2000 words)
Major Professor Letter of Support:	(PDF Format)

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:
Have you ever served in the U.S. military?	Yes No
	Where did you hear about this opportunity?

I certify that all information in this data sheet is true and complete to the best of my knowledge. I also authorize release of information as described in the program guidelines. I understand that submitting false information will disqualify me from participation in Oregon NASA Space Grant programs and opportunities.