Form NSTI 001 NSTI 001 Summer Teacher Institue Application

PTO/NSTI/002 Approved for use through
OMB 0651‐0077
U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
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Doc Code: USPTO NATIONAL SUMMER TEACHER INSTITUTE – July, 2015 NSTI002
Document Description: Application for Participation in USPTO National Summer Teacher Institute
APPLICATION TO PARTICIPATE IN THE USPTO NATIONAL SUMMER TEACHER INSTITUTE (NSTI)
Applicant Name

School Name

School District or County

Applicant Mailing Address

School Mailing Address

School Website

Phone Number
(please indicate work/mobile)

Email Address

Name of approving principal or
administrator

Please answer all questions below and click submit to send via e-mail
1.

If selected for participation in the NSTI, I agree to attend all sessions beginning on July ??, 2015 and
ending on July ??, 2015 and to make reasonable efforts, where applicable, to incorporate the lessons
learned during the Institute in my classroom and school district/county during the 2015-2016 academic
year. In addition, I will cooperate in any reasonable efforts to share my experiences and outcomes with
other teachers at the Institute and with the Office of Education and Outreach at the USPTO.  Yes  No

2.

I have been a full-time, licensed teacher in a middle or high school (public or private) in the United States for
at least three years.  Yes  No

3.

I have a strong desire to incorporate “making,” inventing, or innovation into the learning environment as a
means for enhancing student interest in STEM learning.  Yes  No

4.

I have an interest in increasing student knowledge and understanding of the concepts of intellectual property,
including creation and protection of intellectual property.  Yes  No

5.

Please check all STEM or STEM-related* courses you have taught during the 2014-2015 Academic Year:
STEM is defined as any course in the area of Science, Technology, Engineering, or Mathematics.
 Biology  Chemistry  Physics  Computer Science  Botany  Robotics
 Technology  Engineering  Materials Science
 Algebra  Geometry  Trigonometry  Calculus  Other Mathematics course
 Mechanics  Woodworking  Welding/Shop  Rapid Prototyping
 Graphic Design  Industrial Design  Computer-Aided Design Design Thinking
 Invention Concepts  Creative Thinking  Visualization  Intellectual Property
 Other_________________ (Please specify)

6.

Please check all STEM or STEM-related* courses you will teach during the 2015-2016 Academic Year:
STEM is defined as any course in the area of Science, Technology, Engineering, or Mathematics.
 Biology  Chemistry  Physics  Computer Science  Botany  Robotics
 Technology  Engineering  Materials Science
 Algebra  Geometry  Trigonometry  Calculus  Other Mathematics course
 Mechanics  Woodworking  Welding/Shop  Rapid Prototyping
 Graphic Design  Industrial Design  Computer-Aided Design Design Thinking
 Invention Concepts  Creative Thinking  Visualization  Intellectual Property
 Other__________ (Please specify)

*STEM-related applies broadly to any content area course that involves the use or application of any field of science, technology, engineering or mathematics or
any combination thereof.

7.

Please check examples of either informal or formal educational programs where you have taught or mentored
students in areas related to one or more of the following: Invention, Innovation, Making, or Entrepreneurship.
 Making/Design/Do-It-Yourself (DIY) projects  Invention Competitions  Robotics Programs
 Science Fair Projects  Scouting  Inventors Club  Entrepreneurship Club
 Computer Science Club 4-H  Other ________________________(Please specify)

8.

I have a strong desire to improve teaching and learning in either formal or informal environments and
especially as it relates to the fields of STEM, innovation, or intellectual property.  Yes  No

9.

My school principal or administrator/superintendent has endorsed my application to the USPTO Summer
Teacher Institute. Endorsement means my principal or administrator is aware of my application to this
program and has agreed to support my efforts to take the lessons learned through participation in this
Institute back to the classroom or to my school district. This also includes support by the administrator to
allow the teacher to cooperate with any reasonable efforts in sharing learning experiences and outcomes with
other teachers at the Institute and with the USPTO.  Yes  No

10. I understand that my principal or administrator may be contacted to verify awareness of my application to
participate in this program.  Yes  No
11. I acknowledge that if I am selected to participate in this program the USPTO may contact my principal or
school administrator to verify their endorsement.  Yes  No
12. Please share any additional information that may be relevant to your interest in participating in the USPTO

National Summer Teacher Institute in July, 2015. (Please limit your response to 250 words or less)

By submitting this application form, the applicant certifies that all of the information and responses to questions are true and accurate to the best of his/her knowledge and belief.
Signature: The applicant must personally sign the form either by
1.
2.
3.

Traditional “pen-and-ink” signature: that is, printing out the form, signing the form, and scanning the form and e-mailing it to [email protected]
Electronic signature: that is, keying in a combination of characters preceded and followed by the forward slash symbol (/) that the applicant has adopted as his or her "signature."
(E.g., /Jane Smith/ or /jms/) and pressing the “Submit” button.
Entering an Adobe® digital signature: that is following the instructions in the Adobe software to create a digital signature and pressing the “Submit” button.
Any one of the three signature formats is acceptable.

Signature
Name (Print/Typed)

Date

Submit

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