LSAMP Undergraduate Priority Registration Form
(Type and Email to LSAMP@calstatela.edu by deadline)
Name: ______________________________
CIN: ________________________________
Phone: _____________________________
Email: ______________________________
Major: ______________________________
Class Level: __________________________
Date: _______________________________
Current Overall GPA: ____________ (do not round)
Current CSULA GPA: ____________ (do not round)
Current Major GPA: ____________ (do not round)
1. Are you an active member in a research lab at CSULA? __________
a. If Yes, please complete the following:
i. Please list all the undergraduate research programs that you will receive support from
(i.e. LSAMP, NIH MBRS/RISE, CREST; NASA; etc.) during the AY 2014 - 2015.
ii. Conferences have you/will you participate in as a presenter or non-presenter during AY
2014-2015:
1. Non-presenter
Conference Name
Date of Conference
Location of Conference
2. Presenter (oral or poster): Please list your presentation using the format
indicated below and indicate if you acknowledged the NSF – LSAMP Grant
number. Also indicate if you received a travel award.
Name (NSF Acknowledgement: YES or NO – ORAL or POSTER)
Citation: Authors. Title of poster. Conference Name (Month Year), Location.
Example:
Eileen Gonzalez (NSF Acknowledgement: Yes – Poster)
Citation: Gonzalez E and Yamazaki KG. Mitochondrial Dynamics in the Type 2 Diabetic
Heart. 2013 Experimental Biology Conference (April 2013), Boston, MA.
3. Publications: Please list your papers in published in recognized journals using
the format indicated below and indicate if you acknowledged the NSF – LSAMP
Grant number.
Example:
Yamazaki KG, Ihm SH, Thomas RL, Roth D, Villarreal F. 2012. Cell adhesion molecule
mediation of myocardial inflammatory responses associated with ventricular pacing. Am
J Physiol Heart Circ Physiol, epub January 20, 2012.
2. Did you participate in an international research program during Summer Quarter 2014? _______
a. If yes, please complete the following:
i. Please list the international research program you participated in.
ii. Location:
iii. Institution you performed research at:
iv. Length of program:
v. Description of summer research project:
vi. Paste 4-5 pictures of your international summer research experience.
3. Did you participate in another summer research program during Summer Quarter 2014? ______
a. If yes, please complete the following:
i. Please list the summer research program you participated in.
ii. Location:
iii. Institution you performed research at:
iv. Length of program:
v. Description of summer research project:
4. Have you/Will you apply to a STEM graduate program during AY 2014-2015? __________
a. If yes, please complete the following table (see example):
Last Name
First Name
Major
Expected Qtr.
and Yr. of
Graduation
Degree Objective
(MA/MS/PhD)/Discipline
Graduate Campus
5. Have you/Will you apply to a Health Professional (HP) or Teaching Credential (TC) program in AY 20142015? ____________
a. If yes, please complete the following table (see example):
Last Name
First Name
Major
Expected Qtr.
Degree Objective
HP/TC Campus
and Yr. of
(MD/DO/DDS/TC)
Graduation
6. Have you/Will you apply for the NSF Graduate Research Fellowship or any other national funding award
during AY 2014-2015? __________
a. If yes, please complete the following:
i. Field of Study:
ii. Proposed Graduate Institution:
iii. Title of Proposal:
7. Have you participated in any of the Graduate School Visit events sponsored by the LSAMP program
during AY 2014-2015? _____________
a. If yes, please complete the following (for each school visited):
i. University:
ii. Date of Event:
8. Have you or are you currently working in an internship within the STEM field? ________
a. If yes, please complete the following:
i. Name of Company:
ii. Location of Internship:
iii. Dates:
iv. Description of work performed during an internship:
9. Please check any other LSAMP activity that you participated in within AY 2014-2015:
 Textbook Loaner Program ______
 Academic Year STEM workshops ______
o Indicate course(s) you participated in and received assistance from LSAMP facilitator in AY
2014-2015:
o _________________________________________________________________
 December BREEZE ________ (Indicate for which course(s) ________________________
 Served as a LSAMP facilitator ________
 New LSAMP Research Training program ________
 Anything else: ___________________________
10. Are you planning on taking the GRE in AY 2014-2015? _______
a. If yes, please complete the following:
i. When? ______________________________
ii. Provide a copy of your scores.
11. Are you employed in a STEM (science, technology, engineering, mathematics) position? ______
a. If yes, please complete the following:
i. Name of Company or Organization: _________________________
ii. Where located (City, State)? ____________________________
iii. Dates of employment: _________________________________
iv. What exactly do you do for this employment?
12. Were you enrolled in the Freshman Introduction to Higher Education course (e.g., NSS 101; CS 101;
ENGR 101; UNIV 101; HHS 101) in AY 2014-2015? ___________
a. If yes, indicate when (F14, W15, or SPR15)? ______________
b. Note that a grade of C or higher will be required to qualify for priority registration on this
criteria.
13. Were you enrolled in Transfer Introduction to Higher Education course (e.g., NSS 301; UNIV 301; HHS
301) in AY 2014-2015? _______________
a. If yes, indicate when (F14, W15, or SPR15)? ______________
b. Note that a grade of C or higher will be required to qualify for priority registration on this
criteria.
14. Did you transfer from a California Community College (2-year school) to CSULA in SPR14, SUM14, F14,
W15, or SPR15? ______________
a. If yes, Name the California Community College: __________________________
b. Which quarter did you transfer to CSULA? ________________________
15. Courses you INTEND to take next quarter
Course Name
Course #
e.g CHEM 101
#123567