Last Name:                First Name M.I.

Runner ID Social Security (xxx-xx-xxxx)

Birthday (mm/dd/yyyy)     Gender: Male     Female

Current Address:        

City:          State:     Zip:    

Current Phone (area code first):         Cell Phone (area code first):       

Email:

Current School:          Level:

US Citizen         Permanent Resident          Other         

Race-Ethnicity (Check all that apply):

African-American       Native-American           Hispanic        

Pacific-Islander         Other (specify)

College you plan to attend.    CSUB         BC

Proposed Major (Check all that apply):  

Biology             Chemistry      Computer Science      Engineering

Geology        Mathematics                       Physics            Pre-Med    

Career Goal:

Did you participate in?

          Mesa:                               YES    NO

          Career Beginnings:          YES    NO

Other:                               (Please Specify)

Are you planning to participate during the Summer of 2008 in?

           LSAMP Math Summer Program:              YES    NO

           Summer Bridge:                                       YES    NO

           Career Beginnings:                                   YES    NO

 College Assistance Migrant Program:       YES    NO

Other:                                                       (Please Specify)

Please list the scores of all exams you have taken:

SAT (verbal):      SAT (math):     ACT (English):     ACT (math):

ELM:      EPT:     Other:

YOU CANNOT JOIN LSAMP IF YOU HAVE NOT FULFILLED THE ELM REQUIREMENT.

List the most recent high school or college level classes that you have taken in science and mathematics:

 CLASS                                              LEVEL                       LETTER GRADE

If applying to LSAMP due to economic barriers check the following:

Dependent     Independent. Yearly Income $  If dependent, people in parents household:If independent, Married? Yes    No

If accepted, you will be required to sign the following:

I hereby apply for admission to the CSUB-LSAMP Program. I authorize CSUB-LSAMP to access my grades, university records, and release academic information as requested by funding agencies. I understand that this data will be treated confidentially. I also grant permission for CSUB-LSAMP to use my photograph and quotes in promotional materials.

Please obtain a letter of recommendation from a math/science teacher in your school and fill in the Eligibility Criteria for CSUB-LSAMP form, and send them with  a transcript before June 13, 2008 to 

Professor Javier Trigos

LSAMP Coordinator

Department of Mathematics

California State University, Bakersfield

Bakersfield, CA 93311

Supported by the National Science Foundation grant number HRD-0331537 and the CSU Chancellor's office