Funded by the National Science Foundation (NSF
Eligibility: Students must be a Junior or Senior, and must major in a Science, Technology,
Engineering, or Mathematics (STEM) field.
Note: Application package must include the following: One-page statement outlining why you should be considered for this program; Copy of Unofficial Transcript, List of STEM Courses Taken, and three recommendations (two from STEM Faculty – form can be accessed at www.tnstate.edu/hbcu_up)
PLEASE CHECK POSITION FOR WHICH YOU ARE APPLYING:
________ Peer Mentor/Tutor for STEM Rising Freshman Summer Institute, June 5-July 8, 2011
________ Peer Mentor for Fall 2011 and/or Spring 2012
________ STEM Tutor for Fall 2011 and/or Spring 2012
NAME _________________________________________________________________________
(Please print or type) First Middle Last
STUDENT ID NUMBER __________________________ GPA __________________________
MALE __________________ FEMALE ______________
LOCAL MAILING ADDRESS: _____________________________________________________
________________________________________________________________________________
IF YOU ARE NOT A U.S. CITIZEN, DO YOU HAVE A PERMANENT VISA? ______________
TELEPHONE ( ) ________________________ CELL PHONE ( ) _______________________
BIRTH DATE ________________ EMAIL ADDRESS __________________________________
STEM MAJOR _________________________

JUNIOR OR SENIOR STANDING (as of Fall 2011) ______________________________________
EXPECTED DATE OF GRADUATION _____________________________________
YEARS OF EXPERIENCE AS MENTOR and/or TUTOR ____________________________
ACADEMIC HONORS AND AWARDS (please list)
COMMUNITY SERVICE INVOLVEMENT AND ORGANIZATIONAL AFFILIATIONS (please list)
To the best of my knowledge, the above information is correct.
__________________________________________ _____________________
Signature Date
DEADLINE FOR SUBMISSION OF APPLICATION PACKAGE: FRIDAY, APRIL 15, 2011. Please submit your complete application package to: Dee Green, Research and Sponsored Programs Building, Room
123, ext. 1663 ( dgreen10@tnstate.edu
). Note: Incomplete application packages will not be considered.