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HBCU/MEI

Faculty Summer Research Program

Application Form *Please type or print clearly.*

1.  Choice of Research Project (Number and Letter Designation)

1st Choice 2nd Choice

2\. Requested Dates From To

3\. Name 4. Institution

5\. Department Phone 6. Department

7\. Office Phone 8. Office Fax

9\. Street Address

10\. City, State, Zip

11\. Permanent Address

12\. Home Phone 13. E-mail

14\. U.S. Citizen? Other Citizenship? Permanent Resident Alien?

Yes No Country Yes No

Foreign Nationals Please Provide:

A. Visa Type B. Visa Expiration Date

15\. Education

Highest Degree Earned Major Institution/Campus Date

16\. Employment Record (begin with current)

From To Employer Position/Rank Nature of Work

![](media/image1.wmf){width="2.173611111111111in"
height="0.3902777777777778in"} HBCU/MEI

Faculty Summer Research Program

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17\. List two professional references who have been asked to transmit
recommendation directly to ORISE. Please state name, address, and
telephone number.

1\.

2\.

18\. List member of facility scientific staff with whom you have had
contact.

I understand that all information supplied in support of this
application will be transmitted to ORNL.

Signature of Applicant Date

Return To:

Norma Patterson

HBCU/MEI Faculty Summer Research Participation Program

Oak Ridge Institute for Science and Education

Science and Engineering Education

P. O. Box 117, MS 36

Oak Ridge, Tennessee 37831-0117

Overnight Address:

Norma Patterson

HBCU/MEI Faculty Summer Research Participation Program

Oak Ridge Institute for Science and Education

Science and Engineering Education

1299 Bethel Valley Road, Building SC-200,

Oak Ridge, Tennessee 37830

E-mail: <Norma.Patterson@orau.org> Phone: (865) 241-2877

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**APPLICANT DATA**

Applicant data are important in assessing the effectiveness of our
efforts to solicit applications from a diverse population. Your
completion and submission of this form will assist us in this regard;
however, your failure to do so will not affect our decision regarding
your application. We appreciate your cooperation.

Name Date

Program Applied For

Race ( ) Caucasian (Having origins in any one of the original peoples of
Europe, North

Africa or the Middle East)

( ) Black (Having origins in any of the Black people of Africa)

( ) Hispanic (Of Mexican, Puerto Rican, Cuban, Central/South American or
other

Spanish culture of origin, regardless of race)

( ) American Indian (Having origins in any of the original peoples of
North America,

and maintaining cultural identification through tribal affiliation or
community

recognition)

( ) Asian or Pacific Islander (Having origins in any of the original
peoples of the Far

East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands --
for

example, India, China, Japan, Korea, Philippine Islands, and Samoa)

Sex Date of Birth (Month, Day, Year)

Do you have physical/mental disabilities (physical or mental impairment
that substantially limits one or more major life activities \-\-- for
example, blindness, deafness, or mobility impairment)?

Yes No

Return To:

Norma Patterson

HBCU/MEI Faculty Summer Research Participation Program

Oak Ridge Institute for Science and Education

Science and Engineering Education

P. O. Box 117, MS 36

Oak Ridge, Tennessee 37831-0117

Overnight Address:

1299 Bethel Valley Road, Building SC-200

Oak Ridge, Tennessee 37830

E-mail:

<Norma.Patterson@orau.org>