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SPSU PSLSAMP Scholars Application

In order to apply, please submit a completed application which includes an essay and a list of two references with contact information. References must not be close relatives like fathers, mothers, cousins, uncles, etc; but rather, someone who is/was your teacher/faculty, supervisor, pastor, coach, or other, and has observed your involvement in various activities for a year or more.

The application deadline for Spring 2008 is December 2007.

*** NOTE - If you got an error trying to apply online, it most likely is the result of leaving something blank. Please do not leave any of the fields blank else an error will occur. If there is no info, just put "N/A" (without the ""). ***

Personal Data

1. Semester applying for: Spring 2008 Summer 2008 Fall 2008 Spring 2009 Summer 2009 Fall 2009
2. First Name:
3. Middle Name:
4. Last Name:
5. SPSU Student
   Identification Number:
6. Mailing Address:
7. City:
8. State: ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FEDERATED STATES OF MICRONESIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARSHALL ISLANDS MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
9. Zip:
10. Daytime telephone:
11. Evening telephone:
12. SPSU E-mail:
13. Major:
14. Expected Graduation Date:
15. GPA:
16. Class Rank: New Student Freshman Sophomore Junior Senior
17. Gender: Male Female
18. Ethnicity: Hispanic Non-Hispanic
19. Race: African American Asian American Native American Multi-Cultural Pacific Islander White other
20. Disability: Yes No
21. Citizenship: US Citizen Permanent Resident
22. You must have every intention of graduating from one of the participating universities in no more than five years total with a baccalaureate degree in a STEM major. Please select the institution(s) you will be willing to attend:
23. Southern Polytechnic State University Fort Valley State University Savannah State University The University of Georgia Bainbridge College Georgia Perimeter College

Reference 1

1. First Name:
2. Last Name:
3. Title:
4. Mailing Address:
5. City:
6. State: ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FEDERATED STATES OF MICRONESIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARSHALL ISLANDS MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
7. Zip:
8. Telephone:
9. E-mail:

Reference 2

1. First Name:
2. Last Name:
3. Title:
4. Mailing Address:
5. City:
6. State: ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FEDERATED STATES OF MICRONESIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARSHALL ISLANDS MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
7. Zip:
8. Telephone:
9. E-mail:

Essay

1. Please submit an essay, no more than 250 words, describing your career goals and how you think this program will assist you in reaching your goals.

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