First Name: Middle Name: Last Name:

Date of Birth (MMDDYY): Email address:

Current Street Address: City: State: Zip

Permanent/Home Street Address: City: State: Zip

Current Phone #: Permanent Phone #:

Race/Ethnic group(optional): Please select one: American Indian or Alaskan Native Asian Black or African-American Hispanic or Latino/Latina Native Hawaiian or Other Pacific Islander White Gender: Please select one Male Female

US Citizen: Yes No

If not a US citizen, are you a permanent resident of the US: Yes No

Current Institution Attending:

Current student classication (as of May of the current year): Please select one: Freshman Sophomore Junior Senior

Expected graduation date (MMYY):

Current cumulative grade point average (out of 4.0):

Last names of three faculty in Chemistry and Biochemistry who you would be interested in working with

(see http://www.chemistry.gatech.edu/Faculty/ for a listing and overview of research projects offered at Georgia Tech)

First Choice: Second Choice: ThirdChoice:

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Undergraduate Research Participation Essay/Justification

Please briefly describe your background, interest in participating in the summer undergraduate research

program at Georgia Tech, and long-term career goals (please copy and paste as plain text):

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Letters of Recommendation have been requested from:

Please select: Dr. Mr. Ms. First Name Last Name of (Dept/Institution)

Recommender email address:

Please select: Dr. Mr. Ms. First Name Last Name of (Dept/Institution)

Recommender email address:

Please download the recommendation form and provide to your recommenders.

Please mail or email a transcript (unofficial is fine) to:CHEM REU Coordinator, School of Chemistry and Biochemistry, Georgia Tech, Atlanta, GA 30332-0400 or ashley.edwards(at)chemistry.gatech.edu.

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Please note that information provided in this application may be used to report statistics to the National Science Foundation

or other reporting agencies in an aggregate report. All information provided will remain confidential.