Application for undergraduates interested in participating in summer research at GIANT in Grenoble through  University of Pittsburgh, Carnegie Mellon University, University of California, Santa Barbara PIRE-HYBRID program.

* Required

*First Name: _________________________________________________

*Last Name: _________________________________________________

*Email address: _______________________________________________

Home Address:________________________________________________

*Phone Number:_______________________________________________
(This would be used only for reaching you in an emergency)

*Citizen Status ( Circle one)        U.S Citizen                 U.S Permanent Resident
(You must be a U.S. Citizen or Permanent Resident to be eligible)

*Institution (Circle one)    University of Pittsburgh       CMU     University of Santa Barbara

*Major Department/Program:____________________________________
E.g., Materials Science and Engineering, Chemistry, Physics

*Matriculation Date _________________________________________________
The month and year are important (if you do not know the day, just use any day)

*Expected Graduation Date_________________________________________________
The month and year are important (if you do not know the day, just use any day); if you will be graduating before July 29, 2018, you are probably ineligible for the program.

*Grade Point Average (e.g., 3.73) ____________________________________________
Based on a 4.0 scale; cumulative.

*Academic Advisor’s Name_________________________________________________

*Academic Advisor’s Email Address __________________________________________

*French Language Skills (circle one)     None      Beginner       Intermediate      Fluent         Other
(You do not need to be able to speak French to participate.)

*Passport/visa :
If accepted to the program, you will need to get a U.S. passport as soon as possible for the French paperwork to be formalized. All costs related to applying for a passport are the responsibility of the student

(http://travel.state.gov/content/passports/english/passports/apply.html).
I do not have a current passport
I hold a U.S. passport (write the expiration date in the “other” field)
I have a Green Card (write the expiration date AND the country you hold your passport from in the “other” field
Other:_______________________________________________

*Have you traveled outside of the United States before?______________

If you have traveled outside of the U.S., for what purposes?
vacation
work
academic program (e.g., study abroad)
internship or research
family or friends
Other

If you have health insurance ?

No

Yes

 

Comments

If any of your above responses need additional explanation or you have concerns, please write them here.

 

 

 

 

 

Demographic Information

The questions asking about demographics are entirely voluntary. The information is used for reporting to the PIRE-HYBRID funding agency, the National Science Foundation, which is interested in the demographics of the U.S. STEM workforce and pipeline.

Gender
Female
Male
Other
Do do not wish to report

Ethnicity
Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish   culture or origin, regardless of race.
Hispanic or Latino
Non-Hispanic nor Latino
Do not wish to report

Race
Check as many boxes as you identify with.

American Indian or Alaska Native. A person having origins in any of the original peoples of North and South   America (including Central America), and who maintains tribal affiliation or community attachment.

Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American. A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Do not wish to report

I am the first-generation in my family (parents or grandparents) to go to college.
Yes
No
Do not wish to report

Do you have a disability?

(From the Americans with Disabilities Act) The term “disability” means, with respect to an individual, (A) a physical or mental impairment that substantially limits one or more major life activities of such individual; (B) a record of such an impairment; or(C) being regarded as having such an impairment.

Yes
No
Do not wish to report

Other Application Materials

1. Why would you like to be involved with the PIRE-HYBRID project? (250-word limit)
2. Why would you like to do research at GIANT in Grenoble (http://www.giant-grenoble.org/en/) and/or be part of the GIANT International Internship program (http://www.internships.giant-grenoble.org/)? (250-word limit)
3. Briefly describe any prior research experience and technical skills you have. (350-word limit)

Once you fill out the form, you will need  to email it  to info@pirehybrid.org  in order to complete your application.