Winter Research Experience
Application Packet
PLEASE DELIVER COMPLETED APPLICATION PACKET TO:
HSI STEM Program
CSULB Foundation Building Suite 120
6300 State University Dr.
Long Beach, CA 90815
(562) 985-4127
Deadline to submit application is Friday, October 17th, 2014 at 5pm
The complete application packet must include:
□ HSI-STEM Winter Research Experience Application Form
□ Unofficial Transcripts from all universities and community colleges attended
□ A Personal Statement (500 words)
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Describe the top 3 reasons/ motivations for selecting a major in STEM? (i.e. educational
experience, family, upbringing, etc.)
What are your short and long term career goals?
How might the HSI STEM Winter Research Experience help you reach your goals?
What do you hope to gain from your participation?
□ One (1) copy of your CSULB ID
**Acceptance into the program is contingent upon qualifications and availability of faculty
in your research area
I certify that I have read the information and included all of the materials listed above in my
application package.
______________________________________________________________________________
Applicant’s Name
Applicant’s Signature
Date
Winter Research Experience
California State University, Long Beach
Hispanic Serving Institution ● Science, Technology, Engineering, Mathematics
Personal Information:
Last Name:
First Name:
CSULB ID#:
Street Address:
City:
State:
Zip:
Date of Birth: ______/______/_________
Cell phone:
Email:
How did you hear about us? □ Fliers □ Course Instructor □ Email □ Academic Advisor □ Class visit
(select all that apply)
□ Other (please specify): ____________________________________________________________
Demographic Information:
Age: ______
Sex:
□ Male
□ Female
□ Transgender
Country of Birth: ____________________
Race/Ethnicity: (please indicate all the categories you identify with below)
□ Native American
□ Asian
□ Black/African American
□ Middle Eastern
□ Pacific Islander
□ White/Caucasian
Are you first generation-educated? □ Yes
□ No
□ Latino/Hispanic
□ Other:
Are you bilingual (English/Spanish)? □ Yes
□ No
Academic Information:
Department:
College of Engineering:
□ Chemical Engineering
College of Natural Sciences & Mathematics:
□ Biological Sciences
□ Civil Engineering & Construction Engineering
□ Chemistry and Biochemistry
Management
□ Environmental Science and Policy
□ Computer Engineering & Computer Science
□ Geological Sciences
□ Electrical Engineering
□ Mathematics and Statistics
□ Mechanical & Aerospace Engineering
□ Physics and Astronomy
Declared major:
Declared minor:
Projected month/ year of Graduation: ________/________
Cumulative GPA: ___________
Are you a transfer student?
Major GPA: __________
□ Yes
□ No
Number of units completed (at the conclusion of
Fall 2012): ___________
Do you have previous research experience (outside of courses)?
Winter Research Experience Application
□ Yes
□ No
Page 2 of 5
Winter Research Experience
California State University, Long Beach
Hispanic Serving Institution ● Science, Technology, Engineering, Mathematics
Completed Coursework:
(Check off all coursework completed using the list below. Provide letter grade received in
the course. If course is in progress, please write “in progress”.)
Grade
Course Number & Title
Grade
Course Number & Title
______
□ BIOL 200 General Biology
______
□ CHEM 111B General Chemistry
______
□ BIOL 205 Human Biology
______
□ CHEM 251 Quantitative Analysis
______
□ BIOL 207 Human Physiology
______
______
□ BIOL 211 Intro to Evolution & Diversity
______
□ EE 200 Trends in Electrical Engineering
□ EE 201 Digital Logic Design
______
□ BIOL 212 Intro to Cell & Molecular
______
□ EE 202 Computer Methods in Engineering
______
□ BIOL 213 Intro to Ecology and Physiology
______
□ EE 211 Electric and Electronic Circuits I
______
□ BIOL 260 Biostatistics
______
□ EE 211L Electric Circuits Laboratory
______
□ CE 101 Intro CE & Construction Eng. Management
______
□ GEOL 102 General Geology
______
□ CE 130 Surveying and Mapping
______
□ GEOL 104 Geology Laboratory
______
□ CE 130L Surveying and Mapping Lab
______
□ GEOL 240 Historical Geology
______
□ CE 200 Materials for Civil Engineering
______
□ GEOL 250 Intro to Field Petrology
______
□ CE 205 Analytical Mechanics I (Statics)
______
□ GEOL 273 Computer Statistical Methods
______
□ CE 206 Computer Programming & CE Applications I
______
□ MAE 172 Engineering Design Graphics
______
□ CECS 100 Critical Thinking in the Digital Info Age
______
□ MAE 205 Computer Methods in MAE
______
□ CECS 105 Intro to Computer Engineering/Science
______
□ MAE 272 Intro to Manufacturing Processes
______
□ CECS 174 Intro to Programming
______
□ MATH 119A Calculus I
______
□ CECS 201 Computer Logic Design I
______
□ MATH 119B Calculus II
______
□ CECS 211 Principles of Computer Engineering I
______
□ MATH 122 Calculus I
______
□ CECS 228 Discrete Structures
______
□ MATH 123 Calculus II
______
□ CECS 262 C for Embedded Programming
______
□ MATH 224 Calculus III
______
□ CECS 271 Introduction to Numerical Methods
______
□ MATH 233 Fundamental Concepts for Adv Math
______
□ CECS 274 Object Oriented Programming
______
□ MATH 247 Intro to Linear Algebra
______
□ CECS 282 C++ for Java Programmers
______
□ PHYS 100A General Physics
______
□ CH E 200 Chemical Engineering Fundamentals
______
□ PHYS 100B General Physics
______
□ CH E 210 Computer Methods in Chemical Engr.
______
□ PHYS 151 Mechanics and Heat
______
□ CH E 220 Chemical Engineering Thermodynamics I
______
□ PHYS 152 Electricity and Magnetism
______
□ CHEM 111A General Chemistry
______
□ PHYS 254 Modern Physics and Light
Winter Research Experience Application
Page 3 of 5
Winter Research Experience
California State University, Long Beach
Hispanic Serving Institution ● Science, Technology, Engineering, Mathematics
Institutions Attended: (Please list all universities, colleges, and community colleges)
Institution
Dates attended
GPA
Research Experience:
Do you have a specific professor with whom you would like to participate in research with? □ Yes
If yes, please provide their information below.
Name: ____________________________________
Department: _______________________________
□ No
If no, please list the names and departments of 3
faculty you would be interested to be paired with for
the program. ** Does not guarantee you will be paired with one
of the faculty you have listed below.
Research topic: _____________________________
Name #1: ___________________________________
__________________________________________
Department #1: ______________________________
Would they be willing to host you in their lab for this
program? □ Yes □ No
If no, please list additional faculty you are interested
in working with in the right column
Name #2: ___________________________________
Department #2: ______________________________
Name #3: ___________________________________
Department #3: ______________________________
Please indicate which research lab experience you prefer. (Select all that apply)
□ Field lab experience involving outdoor data/material collection, as well as working inside the lab running
analysis on the data/materials collected
□ Lab experience involving primarily computational and/or computer based lab experiments
□ Lab experience focusing primarily on carrying out experiments inside a lab
□ Engineering/technology lab experience involving research development, design, integration, and/or
analysis of new products/methods using engineering principals
□ No preference; I am comfortable in any research setting
Winter Research Experience Application
Page 4 of 5
Winter Research Experience
California State University, Long Beach
Hispanic Serving Institution ● Science, Technology, Engineering, Mathematics
References:
Please provide two references (must be a faculty or lab instructor).
Reference Name:
Department:
Phone:
Course Taken with this Instructor:
Email:
Grade Received:
Reference Name:
Department:
Phone:
Course Taken with this Instructor:
Email:
Winter Research Experience Application
Grade Received:
Page 5 of 5