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SMC/UCLA Science and Research Initiative
2012-2013 Academic Year
Priority Deadline: Friday, June 29, 2012
The SMC/UCLA Science and Research Initiative program is funded by an HSI (Hispanic-Serving Institution) STEM and Articulation grant from the U.S.
Department of Education. Please complete all items and print clearly. Return the completed application to Debbie Ostorga or Vanessa Bonilla in the
Latino Center located in the Counseling Complex. Please email ostorga_debbie@smc.edu or bonilla_katia@smc.edu if you have any questions.
Section I
First Name: ______________________ Middle (or initial):_____________ Last Name:______________________
Gender:  Male  Female
Birth Date:____/____/____
SMC ID __ __ __ __ __ __ __
Street Address:____________________________________ City:_________________ Zip code:_______________
Home Phone: (
) __________________ Cell Phone: (
) ______________________
E-mail: _________________________ Are you employed?  Yes  No If yes, how many hours per week? ____
Ethnicity: (1)____________________________ (2) ____________________________
What is the primary language spoken in your home? ____________________________________________________
Are you a veteran?
 Yes  No
Are you new to college or a continuing student?  New  Continuing
If you are a new college student, please proceed to Section III. If you are a continuing student or have attended another college,
please fill out Section II.
Section II Only complete this section if you have attended another college or are a continuing SMC student
When did you first enroll/will you first enroll at SMC: ____/_____
Total number of transferable college units completed:  0-29  30-60
Have you attended another college? If so, please list the institutions:________________________________________
Current college GPA: _____
Current science and math classes: _______
Completed science and math courses (any college): _______
Do you have a Bachelor’s degree?
 Yes
 No
_______
_______
_______
_______
_______
_______
_______
If yes, what was your major?___________________________
Section III
Which high school did you attend? ________________ Graduation date: ______ (you need not have graduated to be eligible for the program)
If not California, please list city/state:_______________________________
The SMC/UCLA Science and Research Initiative targets students in Math 20 or higher. Are you currently enrolled in OR have
successfully completed Math 20?  Yes  No
Intended Major:________________
Target Transfer Semester/Year: _____/_____
Section IV
Highest level of education achieved by each of your parents/guardians
(please indicate by using letters A-J for each parent):
_______Father
_______Mother
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
No school/elementary school
8th grade or less
Some high school
High School graduate
Some college/university
Community college degree
4-year college degree
Professional degree (law, medical, M.S./M.A. /Ph.D.,etc)
Other _________________________
Don’t know
Have you applied for financial aid (if applicable)?
 Yes  No
If you applied for financial aid, are you currently receiving
aid?  Yes  No
Do you receive the Board of Governors (BOG) Fee
Waiver?
 Yes, I receive BOG A OR  Yes, I receive BOG B
 No, I do not receive the BOG Fee Waiver
Do you currently receive assistance from Disabled
Student Programs and Services (DSPS)?  Yes  No
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Section V
If you file your own tax return to the Internal Revenue Service, please provide your total yearly income. If you do not file your
own tax return, please provide your parent’s income information if they claim you as a dependent in their tax return.
Total Yearly Household Income:
 $0 - $15,315
 $15,316 - $20,535
 $20,536 - $25,755
 $25,756 - $30,975
 $30,976 - $36,195
 $36,196 - $41,415
 $41,416 - $46,635
 $46,636 - $51,855
 $51,856 - $57,075
 $57,076 - $62,295
 $62,296 or more
Family size (include yourself, your parents and anyone else currently living in your household):_________
Section VI
What is your race/ethnicity? Please check one or more.
Hispanic/Latino
 Mexican, Mexican-American, Chicano
 Central American
 South American
 Other:_________________________________
African American/Black
 African American
 African
 Caribbean
 Other:_________________________________
White/Caucasian
 European/European Descent
 Middle Eastern/Middle Eastern Descent
 North African
 Other/White Caucasian
Asian/Asian American
 Asian Indian
 Cambodian
 Chinese
 Filipino
 Japanese
 Korean
 Laotian
 Vietnamese
 Other: _________________________________
Pacific Islander
 Fijian
 Guamanian
Hawaiian
 Samoan
 Tongan
 Other:__________________________________
 American Indian/Alaska Native
Applicant Signature______________________________
Date___________
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Name:_____________________
ID#________________
SMC/UCLA Science and Research Initiative
1. Why do you want to pursue a major in a STEM (science, technology, engineering or mathematics)?
2. What challenges have you had to overcome thus far to pursue your educational goals? What potential
challenges do you foresee in the future?
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3. How will the SMC/UCLA Science and Research Initiative help you reach your academic and career goals?
4. Please tell us more about yourself. Is there any additional information you would like considered as we
review your application?