SUNY LSAMP Bridge to the Doctorate: University at Albany
A National Science Foundation funded program
PROGRAM APPLICATION
Please review the application carefully. Please print legibly or type your responses.
PART I – DEMOGRAPHIC INFORMATION
Full Legal Name:
Last
First
Middle
Date of Birth (MM/DD/YY):
Gender:
Female
Male
Citizenship:
US Citizen (born or naturalized)
Other (Please specify birthplace:
US Permanent Resident; Registration #
)
Ethnicity:
Black or African American
Pacific Islander (Micronesia, Guam, etc)
Asian (Filipino, Indian, Chinese, etc)
Hispanic/Latino
Alaskan Native
Caucasian
Native American
Multi-Ethnic (Please specify
Have you served in the military:
yes
no If yes, what branch
)
Dates of service:
Home/Permanent Mailing Address:
Current Mailing Address (if different from left):
Number and Street Name
Number and Street Name
City,
State
ZIP Code
Preferred Address for Correspondence:
Daytime Telephone #:
City,
Permanent
State
ZIP Code
Current, Valid Until Date:
Evening Telephone #:
Preferred Email Address (please double-check for clarity):
PART II – EDUCATIONAL INFORMATION
Undergraduate Institution:
Current Status:
JR
___
SR
City, State:
________
Expected Graduation Date (MM/YY):
Major #1:
Major #1 GPA:
/4.0 scale
Major #2, if applicable:
Major #2 GPA:
/4.0 scale
Minor(s), if applicable:
Cumulative GPA: _______ /4.0 scale
GRE Date, if taken (MM/YY):_________________________
GRE Exam Scores: GRE : Verbal
Quantitative
Analytical
Indicate if you have participated in any of the following programs:
MARC
GRE Subject
MBRS
McNair
CSTEP
AGEP
2013 SUNY LSAMP Bridge to the Doctorate Application – Page 1
Have you applied for or have been
awarded other graduate fellowship
support?
If yes, please indicate:
YES :
No :
Source of support:
Amount of support :
PART III – RESEARCH BACKGROUND
Please briefly describe your research interests:
Please list any attendance at professional conferences, presentations, awards won, or articles co-authored:
___________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
PLEASE DESCRIBE YOUR CAREER GOALS AND PATH OF GRADUATE STUDY (IF YOU NEED MORE SPACE, PLEASE ATTACH
A SEPARATE SHEET):
2013 SUNY LSAMP Bridge to the Doctorate Application – Page 2
PART IV – FUTURE PLANS
What department/program are you applying to at University at Albany? _________________________________________
What degree are you applying for?
MA/MS
PhD
Other
PhD
What is your ultimate degree objective?
MA/MS
Not Sure
MD
Please check all of the following that match your
future aspirations.
College or University Professor
Medical Doctor
Other
Have you completed the graduate school application?
Yes
MD/PhD
Research Scientist
No
PART V – INVOLVEMENT WITH LOUIS STOKES ALLIANCE FOR MINORITY PARTICIPATION (LSAMP)
Level 1 LSAMP Students
Contact information of LSAMP staff person who can confirm your involvement in the LSAMP program at your campus:
Name: _________________________________________
Title: ___________________________________________
Phone Number: __________________________________
Email Address: ____________________________________
Level 2 LSAMP Students (You must fill out the Level 2 Eligibility Form to qualify(See attached)
Name: _________________________________________
Title: ___________________________________________
Phone Number: __________________________________
Email Address: ____________________________________
I hereby give permission to the SUNY LSAMP Bridge to the Doctorate program at University at Albany to contact the LSAMP or
Collaborative Program staff person listed above in order to get information about my academic record and program participation.
Signature of Applicant:
________
Date:
_____
PART VI – VERIFICATION
Please read the following carefully and sign only if you are in agreement:
1. I certify that I am a U.S. citizen or Permanent Resident of the U.S.
2. I certify that I have participated in an LSAMP as an undergraduate.
3. I agree that I am committed to the pursuit of a Ph.D.
4. I certify that I am not currently and have not previously enrolled in a graduate program.
5. I understand that my eligibility to continue in the Bridge to the Doctorate program is contingent on my enrollment in a Science,
Technology, Engineering or Mathematics field as specified by the National Science Foundation.
6. I understand that the Bridge to the Doctorate Program has a full-time minimum enrollment requirement.
7. I understand that this program will be considered full-time employment and that I cannot be employed by any other agency or
obtain any other scholarship/fellowship.
8. I understand that I will not be allowed to continue in the Bridge to the Doctorate Program if my academic progress does not meet
enrollment requirements, and semester and cumulative GPA requirements as stated in the program guidelines.
9. I understand that if I am accepted as a Bridge to the Doctorate fellow, I am expected to participate fully in all activities and/or
seminars and provide information in a timely manner as required.
10. Upon acceptance to the program, I grant permission to the University at Albany to use my photograph, selected quotes and/or
profile information on their website and future publications.
11. I hereby certify that all statements in this application are true to the best of my knowledge and understanding.
12. I authorize the investigation of all statements contained in this application and further authorize any person, school, current, and
past organizations named in this application to provide the fellowship program with records, information, and opinions that may be
2013 SUNY LSAMP Bridge to the Doctorate Application – Page 3
useful in making a grand determination and for federal reporting purposes. I release all informants from all liability for damage that
may result from furnishing information and opinions which are truthful and made in good faith to the fellowship program. I
understand that, should this application contain any false or misleading information, my application may be rejected. Also, the
fellowship program can seek restitution for any funds expended.
Certification: I hereby certify that the information provided by me on this application is true and complete. Further, I understand that
my participation in the SUNY LSAMP Bridge to the Doctorate Program at the University at Albany may be denied if any information is
found to be false.
Printed Name of Applicant:
Signature of Applicant:
________
Date:
Please tell us how you heard about the SUNY LSAMP Bridge to the Doctorate at University at Albany:
Professor
Academic Advisor/Program Mentor
Friend/Peer
Family
Flier at a Recruiting Event
University at Albany website
Other:
Thank you for applying to the SUNY LSAMP Bridge to the Doctorate Program! Please submit application materials and direct all
inquiries to:
Betty P. Shadrick, Ph.D.
Director of Graduate Student Diversity
Office of Graduate Studies
University at Albany - State University of New York
1400 Washington Avenue, UAB 121
Albany, New York 12222
(518) 442 - 3899 - Office
(518) 442 - 3922 - Fax
bshadrick@albany.edu
FOR UAlbany OFFICE USE ONLY:
Reviewed by:
AWARD
NO AWARD
Decision Date:
Placement Information
Student first notified of decision via:
Phone
Date:
Email
Date:
Letter
Date:
Fax
Date:
2013 SUNY LSAMP Bridge to the Doctorate Application – Page 4