CSU, Los Angeles
Louis Stokes Alliance for Minority Participation Program
Funded by the National Science Foundation (NSF)
LSAMP Undergraduate INFORMATION UPDATE FORM
FOR CONTINUING PARTICIPANTS ONLY
Applications are accepted year round, but to be eligible for any LSAMP components including Priority Registration, a valid
NEW or CONTINUING STUDENT application must be on file and approved for the year in question. Each year runs
September 1 through August 31 (e.g., current year is September 1, 2015 through August 31, 2016.) Note: It may take 7
days from the date that you submitted your application before it gets approved so plan ahead and submit as early as
possible to be eligible for all components of LSAMP.
Since you already completed the new student LSAMP application form (in fall 2013 or later), you no longer need to fill one
out again. Instead, just take the time to update the following information and respond to the new questions. Each year you
remain an undergraduate student enrolled in a STEM (Science, Technology, Engineering, Mathematics) major and
working on your first bachelor’s degree, we will request that you complete an updated information form. YOU MUST
RESPOND TO QUESTIONS 1-17, EVEN IF YOU HAVE NOT MOVED! Use check list below and make sure you answer
ALL questions! You may bring all of these completed items to the LSAMP office (ASCB – Room 323A) – do NOT submit it
in parts but rather SUBMIT EVERYTHING AT ONE TIME. You should keep this cover page for your own records. If
you prefer, you may mail all of the completed materials including required signatures by you and a faculty advisor to the
following address (be sure to include everything indicated below):
LSAMP Office – ASCB – Room 323A
CSULA c/o M. Jefferson
5151 State University Drive
Los Angeles, CA 90032-8201
LSAMP CHECKLIST
_____
I have answered every question on this application. (Note: your continuation application is considered incomplete if
any question is left blank. Read questions carefully to avoid having your application rejected for missing or
inappropriate responses.)
_____
The information that I have provided is accurate according to information in GET.
_____
My application includes a printout of your Academic Year 15-16 and Financial Aid Summary 15-16 forms regardless of
whether or not I am receiving financial aid (see page 3 of this application for precise instructions on what each of
these forms are and how to obtain them.)
_____
I have included a properly, completed Academic Plan. (See page 4)
_____
The Academic Plan is signed by a major department faculty academic advisor or college advisor (ECST, HHS, or NSS)
or MEP advisor if engineering or computer science major or Dr. Jefferson or Dr. Yamazaki if you are a biology or
microbiology major according to GET (plan ahead; submitting the plan with an invalid or forged signature will result in
dismissal from the program!)
_____
I have signed and dated the Statement of Understanding (page 5)
_____
Stipend forms and Coordination of Aid forms will only be completed at the end of each quarter that you are eligible
for a stipend or book refund. (See page 5 of application for more details).
____
If you are currently doing research in someone’s lab or in the field or in an internship situation, LSAMP may arrange a
time to take a digital photo of you in a research situation. (NOTE: NSF frequently prepares reports on students that
are distributed nationally to graduate schools and employers. We want to make sure that our students get included in
the coverage.)
PLEASE TYPE YOUR RESPONSES TO THE QUESTIONS ON ALL OF THE ATTACHED PAGES and REMEMBER TO GET
SIGNATURES (or the application will not be accepted!)!
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, HRD-1302873
& the California State University’s Office of the Chancellor.
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APPLICATION FOR CONTINUING LSAMP STUDENTS for 2015-2016
MUST TYPE information in boxes on RIGHT side!
Please note that it is your responsibility to notify us immediately, if any of this information changes.
If more space is needed for a question, insert additional page and indicate question #.
1)
First Name:
2)
Middle Initial (type “---------“if no M.I.):
3)
Last Name:
4)
CIN:
5)
Street Address:
6)
Apartment # ( type “---------“ if none):
7)
City:
8)
State:
9)
Zip Code:
10)
Home phone # (e.g., 555-555-555):
11)
Cell phone # ( type “---------“ if none):
12)
Personal Email address ( type “---------“ if none):
13)
14)
15)
16)
17)
Will you be receiving any type of financial aid
(scholarships, grants, loans etc. – this includes
stipends and salary from other programs at
CSULA) this upcoming year (2015-2016)? Yes
or No
Will you be graduating this upcoming year (F
2015; W 2016; SP 2016; SU 2016)? Yes or No;
If yes, also indicate which of these 4 terms!
(Please submit original receipt for refund)*
What is your major according to GET?
During the past year (September 1, 2014
through August 31, 2015) were you doing
research or an internship with anyone? Yes or
No; If yes, also indicate where specifically it was
done, with whom, when - specific dates or
quarters, and provide brief description of what
you did. Students who are or were engaged in
research or have internships are eligible for
increased incentives depending on specific
activity and verification of activity
If you are graduating in F2015, W2016, SP2016,
or SU2016, are you applying to graduate school
(Masters or PhD programs only for Fall 2016
start date)? Yes or No; If yes, also indicate
where, which degree (MS or PhD) & what
major? Students accepted to graduate school
are eligible for increased incentives.
*Include with the original receipt for graduation application & diploma fee – ($30 total) the following on a separate piece of paper attached to the
receipt: your complete name and mailing address as well as phone number, email address, and CIN. Reapplications NOT funded.
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, HRD-1302873
& the California State University’s Office of the Chancellor.
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APPLICATION FOR CONTINUING LSAMP STUDENTS for 2015-2016
MUST TYPE information in boxes on RIGHT side!
Please note that it is your responsibility to notify us immediately, if any of this information changes.
If more space is needed for a question, insert additional page and indicate question #.
If you are graduating in F2015, W2016, SP2016,
or SU2016, are you applying to professional
school medical, dental, pharmacy, etc. programs
for Fall 2016 start date)? Yes or No; If yes, also
indicate where and which degree program.
If you are graduating in F2015, W2016, SP2016,
or SU2016, are you applying for teaching
positions? Yes or No; If yes, also indicate
where and what level (elementary, junior high, or
high school).
If you are graduating in F2015, W2016, SP2016,
or SU2016, are you applying for STEM-related
employment? Yes or No; If yes, also indicate
where and what position.
18)
19)
20)
FINANCIAL AID INFORMATION
Important – Read this page carefully even if you do NOT receive financial aid.
A. Regardless of whether or not you are receiving financial aid (which includes scholarships, loans, grants from other
programs at CSULA), PRINT 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:
Academic Year 15-16 form
Financial Aid Summary 15-16 form
2. Log into your GET account.
3. Go to the Student Services Home Link.
4. Go to FINANCES Link.
5. Look under FINANCIAL AID & click on VIEW MY FINANCIAL AID Link.
6. Select the appropriate year you want to look under.
7. 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 (if anything) in 2015-2016 by
each quarter (PRINT THIS PAGE).
8. Next scroll down near bottom of that same page and click on FINANCIAL AID SUMMARY 15-16
9. Now you will be viewing your FINANCIAL AID SUMMARY 15-16, which shows your UNMET NEED for
both AY15-16 (PRINT THIS PAGE) and SU15 (PRINT THIS PAGE).
10. Submit the two-three pages that you just printed out to the LSAMP office with this application.
1.
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, the money you 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).
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
& the California State University’s Office of the Chancellor.
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LSAMP ACADEMIC PLAN FOR CSULA PARTICIPANTS
(Complete this one year plan with an academic advisor listing when you will take specific requirements)
Please sign the form and have a faculty academic advisor also sign the form (see checklist for other
individuals who can sign form. Provide all information requested. Indicate the total units that you will take each
quarter. Under the Course # column use the proper department abbreviations (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 200A; etc). Under the Units column, specify the number of units that the course is worth (Do NOT
separate lecture and lab components – they are just one course). Academic progress is a requirement of
LSAMP! *If not enrolled in SUMMER 2016 classes, explain what you plan to do in SU16. THIS Page MUST
BE TYPED, then printed out and proper signatures obtained (see checklist on page one)! Failure to
follow these instructions will result in rejection of your application.
Student's Name: _______________________________
Major: _______________________________
CIN: _________________________________________
Date: ____________________________________
Minor (specify if any or indicate none if no minor): ______________________________________________
QTR/YR: FALL 2015
Course #
Units
Total Units
QTR/YR: WINTER 2016
Course #
Units
Total Units
QTR/YR: SPRING 2016
Course #
Units
Total Units
QTR/YR: SUMMER 2016*
Course #
Units
Total Units
Your Signature: _____________________________________
PRINT Last Name of Advisor*: __________________________
Proposed Graduation Quarter & Year: _________________
Advisor's Signature*: __________________________________
Passed WPE in ______________________________________
Current CUM GPA (look up in GET):________________________
(if not yet taken, state NOT TAKEN on line above)
*Last Name of Advisor should agree with the name of the person who will sign this document as advisor.
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, HRD-1302873
& the California State University’s Office of the Chancellor.
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The LSAMP REPORT FORM must be completed to determine possible eligibility for priority registration or
stipends. You must submit the LSAMP REPORT FORM by the deadline (which will be indicated on the form).
Please note that in order to receive priority registration for any given quarter you must also complete two
STEM seminar evaluations each quarter and actively participate in one or more LSAMP activities. If you are
eligible for a stipend during the 2015-2016 AY, we will ask you to sign a stipend form and a vendor form. We
will also complete a Coordination of Aid (COA) form that must be approved by the Office of Financial Aid.
Please note that since stipends are based on your participation, degree progress, internship or research
involvement and academic performance overall, stipends are not usually awarded until the end of quarter or
in many cases at the end of the academic year. The stipend form requires that we include the following
information (so complete the appropriate information and be certain to let us know if this information changes
during the year).

_____ I do NOT work on campus.

_____ I do work on campus in the following position:

Title of your position: ________________________________________

Name of Department: ________________________________________

Hourly compensation: _$__________________per hour_____________
Please read the statements below, print your name, sign where indicated, and date this form:
The information which I have submitted in my CSU-LSAMP Undergraduate Program Application is true and
accurate to the best of my knowledge. I understand that to track the progress of CSU-LSAMP participants
and to evaluate program effectiveness, CSU-LSAMP requires access to student information. The CSULSAMP 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 CSU-LSAMP 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 also understand that when I submit abstracts, research papers, and give poster or oral presentations I must
properly acknowledge the CSU-LSAMP grant in the following format at the end of the abstract when I submit
the abstract and on the poster itself: Supported by NSF funds (HRD-1302873) to CSU-LSAMP and Office
of the Chancellor funds.
I have read and understand all of the statements above.
Printed Name of Applicant:
___________________________________________________________
Signature of Applicant:
___________________________________________________________
Today’s Date:
___________________________________________________________
Funding for the CSU-LSAMP Program is provided by the National Science Foundation, HRD-1302873
& the California State University’s Office of the Chancellor.
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