NAME: ______________________________________ ID#:__________________

ADDRESS (PERMANENT):

__________________________________________________________________

CAMPUS BOX/LOCAL:

__________________________________________________________________

TELEPHONE (PERMANENT):

(     )___________________

CAMPUS/LOCAL:

 (___)__________________

E-MAIL ADDRESS:  _____________________________________

CURRENT ACADEMIC STATUS (i.e., Junior): ______________________

MAJOR:  _____________________  MINOR:  _______________________

EXPECTED MONTH/YEAR OF GRADUATION: ______________________

GRADE POINT AVERAGE: ______________________

GRADE POINT AVERAGE IN MAJOR: ______________________

TITLE OF PROJECT:________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

REQUESTED GRANT PERIOD:(Month/day)____________ TO:(Month/day)___________

FACULTY ADVISOR:________________________________________________________

DEPARTMENT:_____________________________________________________________

ARE YOU A CANDIDATE FOR ANOTHER GRANT? YES__________ NO_________

IF YES, EXPLAIN___________________________________________________________

SIGNATURE________________________________________DATE__________________