CALIFORNIA STATE UNIVERSITY LOUIS STOKES ALLIANCE FOR
MINORITY PARTICIPATION PROGRAM (CSU-LSAMP)
APPLICATION
CAMPUS: Los Angeles
YEAR: 2015-2016
Initiated in 1993-1994, CSU-LSAMP is an alliance of the 23 campuses of the California State University (CSU)
system which supports a coordinated and comprehensive system-wide approach to broadening participation in
science, technology, engineering and mathematics (STEM) disciplines.
Each of the CSU campuses has a CSU-LSAMP program that offers an array of activities and services designed
to improve retention and graduation of undergraduate students in STEM. In addition, CSU-LSAMP seeks to
increase the number of CSU-LSAMP students who enter STEM graduate programs.
To be eligible to participate in CSU-LSAMP, students must:
 Be a U.S. Citizen or Permanent Resident.
 Be enrolled at a participating campus in an undergraduate major in a STEM discipline or have expressed an
interest in pursuing a STEM baccalaureate degree.
 Be an individual who has faced or faces social, educational, or economic barriers to careers in STEM.
 Each CSU-LSAMP campus program may have additional eligibility requirements. Please see the Campus
Coordinator.
I. GENERAL INFORMATION
Name:
Gender:
Last
First
Middle
Male
Address:
Female
Street
Telephone: (
City
)
Zip Code
Email:
Please include area code
Date of Birth:
Place of Birth:
City, State, & Country
Social Security #:
Citizenship:
U.S. Citizen
Permanent
Resident
If applicable, Permanent Resident Registration #:
Please mark one of the boxes provided for both “Ethnicity” and “Race.”
Ethnicity (for statistical purposes only):
Not Hispanic or Latino
Hispanic or Latino (A person of Mexican, Puerto
Rican, Cuban, Central or South American, or other Spanish
culture or origin, regardless of race)
Decline to State
Race (for statistical purposes only):
Black or African-American - A person having
origins in any of the black racial groups in Africa
Native Hawaiian or Other Pacific Islander
- A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, Polynesia, Micronesia, or other
Pacific Islands
American Indian - A person having origins in any
of the original peoples of North America and maintaining
cultural identification through tribal affiliation or community
recognition
Alaska Native - A person having origins in any of
the original peoples of Alaska, including Eskimos or Aleuts
Asian - A person having origins in any of the original
peoples of East Asia, Southeast Asia, or the Indian
subcontinent. This area includes, for example, China, India,
Indonesia, Japan, Korea, and Vietnam
White - A person having origins in any of the original
peoples of Europe, North Africa, or the Middle East
Other (specify):
Decline to State
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, HRD-1302873
and the California State University’s Office of the Chancellor.
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Name of Applicant:
Institution: California State University, Los Angeles
II. PERSONAL INFORMATION
A.
Please indicate your parents’ level of education:
Mother:
No College
Some College
College Graduate
Graduate School
Father:
No College
Some College
College Graduate
Graduate School
B. Disability Status (again, for statistical purposes only): Please check “yes” if any of the
disabilities listed below the check box apply to you. Otherwise, check no or decline to state.


Yes
No
Deaf or serious difficulty hearing
Blind or serious difficulty seeing even when
wearing glasses
C. Are you a veteran of the U.S. Armed Forces?
Decline to State
 Serious difficulty walking or climbing stairs
 Other serious disability related to a physical,
mental, or emotional condition
Yes
No
Decline to State
D. As an undergraduate, are you eligible for need-based financial aid?
Yes
E. Are you treated as an independent student for financial aid purposes?
No
Yes
No
F. What is your Personal yearly income?
Less than $10,000
$10,001 - $20,000
$20,001 - $30,000
More than $30,000
G. What is your Family’s yearly income?
Less than $10,000
$10,001 - $20,000
$20,001 - $30,000
More than $30,000
III. EDUCATIONAL INFORMATION
Major:
Minor (if any):
Class Level:
(e.g. freshman, sophomore, junior, senior)
Total Number of Units Completed:
_____
Semester
Total Number of Major Units Completed:
Quarter
Semester
Quarter
GPA (Do not round up – 3 decimal places available in GET):
Cumulative GPA
Date you expect to receive your CSU Undergraduate Degree:
Major GPA
_____
Anticipated Undergraduate Degree (BA/BS):
Did you transfer from a California Community College (2-year school)?
Yes
If yes, which college:
If yes, how many units did you complete prior to transferring?
Did you complete an Associate’s degree?
Yes
No
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, HRD-1302873
and the California State University’s Office of the Chancellor.
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No
Name of Applicant:
Institution: California State University, Los Angeles
IV. ADDITIONAL INFORMATION
A. CSULA CIN:
_____
B. CSULA Email address:
_____
C. First Quarter and Year you enrolled in classes at CSULA:
_____
D. Quarter & Year you plan or hope to graduate from CSULA:
_____
E. Have you completed all lower division MATH requirements (100 and 200-level courses) required for
your major?
Yes
No
F. Have you completed all lower division ENGINEERING and/or SCIENCE requirements (100 and
200-level courses) required for your major?
Yes
No
G. Are you eligible to receive financial aid?
Yes
No
H. Are you receiving financial aid for this academic year?
Yes
No
I. If you answered yes to question G and no to question H, please explain why. Otherwise, type N/A in
gray area:
_____
J. What is your career goal?
_____
K. Have you had any opportunities to do research?
L. Are you currently doing research?
Yes
Yes
No
No
M. Have you had any internship opportunities (paid or unpaid)?
N. Do you currently have an internship?
Yes
Yes
No
No
O. Are you interested in obtaining a graduate degree at the Masters level after you graduate?
No
Maybe
Yes
P. Are you interested in obtaining a graduate degree at the PhD level after you graduate?
No
Maybe
Yes
Q. Are you interested in teaching at any educational level?
Yes
No
Maybe
R. Are you interested in obtaining a professional degree (e.g., MD, OD, DDS, D Pharm, etc.)?
Yes
No
Maybe
S. Do you plan to get a full-time job in STEM (science, technology, engineering, mathematics) as soon
as you complete your undergraduate degree?
Yes
No
Maybe
T. How many hours do you work per week in a typical month?
11-20 hours
21-30 hours
31-40 hours
U. Do you work:
on campus
off campus
0 hours
1-10 hours
greater than 40 hours
I do not work
V. List any STEM clubs on campus in which you are a member:
_____
W. Are you interested in attending the Graduate School Diversity Day Program in November or April (in
your junior or senior year)?
Yes
No
Maybe
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, HRD-1302873
and the California State University’s Office of the Chancellor.
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Name of Applicant:
Institution: California State University, Los Angeles
IV. ADDITIONAL INFORMATION - CONTINUED
X. Are you interested in participating in any research training courses to learn how to do research and
get placed with a research faculty member?
Yes
No
Maybe
Y. Are you interested in attending a professional STEM conference?
Yes
No
Maybe
Z. Are you interested in presenting an oral presentation at a STEM conference?
Yes
AA.
No
Maybe
Are you interested in giving a poster presentation at a STEM conference?
Yes
BB.
No
Maybe
Are you interested in applying for summer internships or research positions?
Yes
No
Maybe
V. FINANCIAL AID INFORMATION – PLEASE READ AND DO EVEN IF YOU DO NOT RECEIVE FINANCIAL AID.
A. Regardless of whether or not you are receiving financial aid (which includes scholarships and grants) from
CSULA, all applicants must PRINT (and SUBMIT with your application) from your GET access the
following TWO forms by following these instructions:
Use the GET Website (https://get.calstatela.edu) to obtain the following two forms:
o
Academic Year 15-16 form
o
Financial Aid Summary 15-16 form
1.
2.
3.
4.
5.
6.
Log into your GET account.
Go to the Student Services Home Link.
Go to FINANCES Link.
Look under FINANCIAL AID & click on VIEW MY FINANCIAL AID Link.
Select the appropriate year you want to look under.
Now you will be viewing the FINANCIAL AID SUMMARY 15-16. We refer to this page as the
Academic Year 15-16 because it shows everything that you are eligible to receive in 20152016 by each quarter (PRINT THIS PAGE).
7. Next scroll down near bottom of that same page and click on FINANCIAL AID SUMMARY 15-16.
8. Now you will be viewing your FINANCIAL AID SUMMARY 15-16, which shows your UNMET
NEED for both SU15 and AY15-16 (PRINT THIS PAGE).
9. Submit the two pages that you just printed out to the LSAMP office (ASC-Wing B, Room
323A) with the rest of your application.
B. If you are receiving financial aid from CSULA, and if you have no unmet need but have loans that you have
accepted as part of your financial aid packet, any funds that you may receive from this program may result in
a reduction in your loans received from Financial Aid. Remember, loans must be paid back and receiving
awards from this program will result in less money you will have to pay back (as long as the information that
you provided is accurate and approved by the Office of Financial Aid).
C. If you are receiving financial aid from CSULA, and if you have no unmet need and no loans as part of your
financial aid package, we MAY NOT be able to provide you with any stipend for which you may be eligible.
The Financial Aid Office determines whether or not you are eligible for a stipend– LSAMP does NOT control
this decision. If you fall into this category, you may be eligible for other incentives.
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, HRD-1302873
and the California State University’s Office of the Chancellor.
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Name of Applicant:
Institution: California State University, Los Angeles
VI. ACADEMIC PLAN – REQUIRED ANNUALLY
Please complete and sign this form and have a faculty academic advisor also sign the form (see checklist for other people
who can sign form). Provide all information requested. Indicate the total units that you will take each quarter. Under the Course #
columns use the proper department abbreviations in UPPER CASE (see page 1 of the Schedule of Classes) followed by the
course number (For example, CHEM 101; BIOL 100A; ME 401; ENGR 300; CS 260; MICR 300A; etc.). Do not separate
lecture and lab unless they are separate courses. Under the Units column, specify the number of units that the course is
assigned. Academic progress is a requirement of CSU-LSAMP @ CSULA! Please pay attention to prerequisites and
proper course numbers – application will be rejected if you arbitrarily list courses that you have no intentions of taking
or have failed to take in the proper sequence.*If you are not enrolled in SUMMER 2016 classes, briefly explain what you will
be doing (THIS INFORMATION MUST BE TYPED); then print this page and obtain proper signatures! Failure to follow these
instructions will result in rejection of your application.
Major:
Minor (if any):
QTR/YR: FALL 2015
Course #
Units
Total Units
QTR/YR: SPRING 2016
Course #
Total Units
QTR/YR: WINTER 2016
Course #
Units
Total Units
Units
QTR/YR: SUMMER 2016*
Course #
Units
Total Units
Your Signature: ___________________________ Academic Advisor's Signature: __________________________
Graduation Quarter & Year (planned):
Passed WPE in
_____
_____ Type Name of Advisor (who signed above):
Current CUM GPA (look up in GET):
___________
_____
(If not yet taken, state NOT TAKEN on line above)
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, HRD-1302873
and the California State University’s Office of the Chancellor.
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Name of Applicant:
Institution: California State University, Los Angeles
VII. Student Signature/Release
Please read the statement below and sign where indicated:
The information I have submitted in my California State University LSAMP Application is true and accurate to
the best of my knowledge. I understand that to track the progress of the CSU-LSAMP students and to evaluate
program effectiveness, CSU-LSAMP requires access to student information. The CSU-LSAMP program is
required to report individual student data to the National Science Foundation including social security number,
ethnicity, GPA, and enrollment status. This information is also used to study student transfer, retention,
progression, and graduation. Photographs and research abstracts may also be obtained for use by the CSULSAMP program in program dissemination materials such as websites, newsletters, and reports. The student
data are collected by the CSU-LSAMP Statewide Office at California State University, Sacramento and each of
the 23 affiliated Alliance CSU campuses.
I authorize release and use of personal information, as described above, to the CSU-LSAMP program. I
understand that this information is to be used solely for evaluating the impact and effectiveness of the CSULSAMP program and that individual student data will not be released to parties other than those directly
involved with the program.
I have read and understand all of the statements above.
Typed Name of Applicant:
Signature of Applicant: _____________________________________________ Date: ______________
VIII. Campus Coordinator Approval and Certification
The above named student is approved as a CSU-LSAMP student?
Yes – Is an individual who has faced or faces (check one)
Social
Educational
Economic barriers to careers in STEM
No – Does not meet eligibility criteria
Printed Name of Campus Coordinator: Dr. Margaret Jefferson or Dr. Katrina Yamazaki
Signature of Campus Coordinator: _____________________________________
Date: ______________
IX. Student Acknowledgement – TO BE SIGNED BY STUDENT UPON APPROVAL TO
PROGRAM
I understand that I have been accepted to the CSU-LSAMP Program and granted
access to the various activities therein. I further understand that I must maintain
expectations explained to me by the CSU-LSAMP Campus Coordinator for continued
involvement in the program.
Signed: __________________________________________
Date: ____________________
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, HRD-1302873
and the California State University’s Office of the Chancellor.
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