NASA C-3074 Student Information

National
Aeronautics and
Space
Administration

Student Information

Name (print)

Gender

Female

Male

Program you are applying for: Dropping In a Microgravity Environment (DIME)
In order to determine the degree to which members of each ethnic and racial group are reached by this announcement,
NASA requests that the student check the appropriate block(s) below. Submission of this information is VOLUNTARY.

Please complete and return with application materials.
Ethnic Background (check one that best applies):
American Indian or Alaska Native (Non-Hispanic)
Asian (Non-Hispanic)
Black or African-American (Non-Hispanic)
Hispanic/Latino(a)
Native Hawaiian or Pacific Islander (Non-Hispanic)
Two or more races
White (Non-Hispanic)

Individual with a disability*

Yes

No

Please list any special accommodations required:

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

The information solicited on this form will not be available to those responsible for reviewing applications, but will be used by
NASA primarily to determine the extent to which various populations are represented in the applicant pool. This information will
remain strictly confidential.

NASA C-3074 (NOV 10)