SURF Application Cover Sheet

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The form may be completed by typing directly into the fields using your keyboard prior to printing. Alternatively, you can print out the form and fill it out by hand.

Last Name:

First Name:

Middle Initial(s):

Project Title:

Institution:

College Address:

Permanent Address:

College Phone:

Home Phone:

Email Address:

Expected Graduation Date:

Major(s):

(Note: Students graduating in May 2004 are NOT eligible for EAST Summer Fellowships.)

Academic standing as of January 1, 2004

Freshman
Sophomore
Junior
Senior

Overall GPA:

GPA in Major:

Optional

Race/Ethnicity:

Gender:

Disability Status:

Research Supervisor

Name:

Institution:

Department:

Address:

Phone:

E-mail Address:

Mail or FAX with rest of application pages to:

Nancy Lightbody
EAST
University of Southern Maine
Lewiston Hall, Building 4
60 Pineland Drive
New Gloucester, ME 04260-5113
FAX: (207) 688-4036

EAST: Eastern Alliance in Science, Technology, Engineering, and Mathematics

SURF Application Cover Sheet