Name of Project:

Name of Supervisor:

1. Name:

2. Social Security #:

3. Email:

4. Level: Graduate Undergraduate

5. Grade Point Average:

6. Current Student Address:

7. Telephone #:

8. Permanent Student Address:

9. Race:

Native American
Pacific islander
African American
Hispanic
Caucasian
Asian
All other students

10. Gender: male female

Field of Study:

11. Primary discipline (ex. Aeronautical):

12. If applicable, secondary discipline:

13. Do you currently hold a degree: yes no

14. Current status: (choose one):

Freshman
Sophomore
Junior
Senior
MS/MA
Ph.D.

15. Highest attained degree:

High school
Associate
Baccalaureate/BA or BS
Master’s/master’s equivalency
Doctorate

16. Number of degrees:

17. Students educational goal:

Bachelors
2nd bachelors
Masters
2nd masters
Ph.D.
post-doctoral

18. Probable field of study for this level?

19. Primary discipline (ex. Aeronautical):

20. If applicable, secondary discipline:

Career Goals

21. After completing studies, you plan to work in:

Higher education
Faculty
Administrative
Other
Private industry
Teaching (K-12)
NASA
Non-NASA Federal Agency
State/local government
Nonprofit organization
Military
Consulting

Please enter a brief synopsis of your proposal in the box below. You must email a copy of your complete proposal to halaris@mit.edu in order for your application to be considered complete.
datafile