LERCIP Application

* Required

()=20 Personal Information

Full legal=20 name is requested
*First Name: = *Middle = Initial:=20 *Last Name: =

*Birth Info

*Birth Date: =20 (mm/dd/yyyy)
*Birth City: = *Birth = State:=20 =
*Birth = Country:=20
= =20 *US Citizen (citizenship will be verified prior to hire) =

*Permanent Address: (Home Address) =

=20 Prior to=20 April 15 send mail to this address=20
= After=20 April 15 send mail to this address

*Street: =

*City:

= *State:

*Zip Code:

*Temporary Address: (while living at = school)=20

=20 Prior to April 15 send mail to this = address=20
= After April 15 send mail to this = address=20

*Street:

=20

*City:

*State:

*Zip Code:

Contact = Info:

*Home Phone: =

*Mobile Phone:

*Alt. = Phone:

*FAX:

*Primary = E-Mail:

*Alt. = E-Mail:=20

()=20 Academic Information

= *College or University (currently attending or = plan to=20 attend)

School=20 Name:

If = not found,=20 enter here:

City:=20

State:=20

Zip = Code:=20

- =

*Academic level at start of next school year:=20

H.S. Seniors select College Freshman =

*Credit hours earned by the end of this = school year:=20

*Total Credit hours required for graduation:=20

*Planned graduation date (mm/dd/yyyy): =

(mm/dd/yyyy) =

*Cumulative GPA out of 4.0:

(must be = supported by school=20 transcripts; min 3.0, max 4.0)

*Degree level currently pursuing:

*Major 1:

If not found, enter = here:

*Major 2:

If not found, enter = here:

*Major 3:

If not found, enter = here:

If currently in college and planning to attend a = different=20 college/univ next Fall, please indicate reason and name of = college/university=20 below:

Reason for changing college/university: = = Transfer Student =20

School=20 Name:

If not=20 found, enter here:

City:

State:

Zip=20 Code:

- =

Please list=20 winter/spring courses for current school year:

=20
=20
=20
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()=20 Placement Information

Placement Information:

Please indicate=20 the discipline in which you would like to intern if positions are = available.=20 Final student placement is determined by mentor's assignment requests. = No=20 internships in Medicine or Veterinary Medicine are offered.

First = choice:=20
Second=20 choice:
Third = choice:=20
Other = discipline if not=20 listed (be specific): =
Select = which session=20 you prefer:
If you were a previous LERCIP participant would you = like to=20 return to the same organization and mentor? =
If=20 yes, you are encouraged to contact the mentor and let him/her know that = you have=20 applied for the program and if summer positions are available in his/her = respective organization, you would like to be considered. Remember there = is no=20 GUARANTEE of a position, as organizational, budgetary and staff needs = change=20 each year.

If=20 you have a relative who works for NASA or NASA contractor please provide = the=20 following information:
Name of = Relative:=20
Relationship to you: =
Company=20 name/area/organization:

*What do you hope to gain from participating in = this=20 program?:

=20
You have characters left.

*How might this experience help you in your = chosen field=20 of study/future career?:

=20
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*Describe any related activities that reflect = your=20 commitment to your major (e.g. internships, memberships in related=20 organizations, related skills, etc.):

=20
You have characters left.

*Attach Resume: = =20
(Microsoft Word .doc or Adobe Acrobat .pdf formats only) =

Please indicate any NASA program you = previously=20 APPLIED for or PARTICIPATED in:

Applied Participated Year Applied Participated Year GRC Engineering Technology GRC N.A.S.A. Project GRC Exploring GRC Shadowing GRC High School GRC TSU Collegebound GRC LERCIP College FIRST GRC LERCIP Scholars = NASA SHARP = GRC NASA Plus = SEMAA =

Other NASA or Internship programs: =

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Involvement with other = NASA=20 programs not listed or other Non-NASA Internship Programs. Please = include name=20 of program and dates of participation.

You have = = characters left.=20

If selected,do you need to be provided with the = program's=20 short-term housing list?: =

Would you like your name and email sent to = selected=20 students interested in shared housing?: =20 =20

()=20 Certification

Certification =

I certify, by entering my name below, that I am a citizen of the = United=20 States of America and that all information contained in this application = is=20 accurate and correct. I further understand and agree that any = misrepresentation=20 or inaccurate information reported on my application will be cause for=20 disqualification for consideration and from participation in LERCIP and = other=20 NASA and OAI programs. If selected to participate, I understand I must=20 participate for the full duration of the program and failure to do so or = abide=20 by the program policies and requirements, safety and security policies, = and=20 completion of required program forms will result in the immediate = termination of=20 my internship and will be just cause for disqualification or = consideration from=20 future participation in LERCIP and other NASA and OAI programs. =

I=20 understand and acknowledge that participation in the program = does not=20 entitle me to unemployment compensation. Type your full name = below to=20 acknowledge your acceptance.

*Student full name:

If under 18 years of age, parent or guardian = name must=20 also be provided below:=20

*Parent/Guardian full name:

=20

()=20 Optional Information

Optional = Information=20

In order to determine the degree to which members of = each=20 ethnic and racial group are reached by this announcement, NASA requests = that the=20 student select the appropriate responses below. Submission of this = information=20 is VOLUNTARY. The information solicited on the form will not be = available=20 to those responsible for reviewing applications, but will be used by OAI = and=20 NASA primarily to determine the extent to which various populations are=20 represented in the applicant pool. This information is strictly=20 confidential.

*Gender:

*Race/National Origin:

Individual with=20 disability*

Please list any=20 special accommodations required:
=20
You have characters left. =

* A person having a physical or mental = impairment that=20 substantially limits one or more major life activities, has a record of = such=20 impairment, or is regarded as having such impairment.=20

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