<p>First Name Last Name</p><p>E-mail Address</p><p>Address</p><p>Street</p><p>City State Zip Code</p><p>Phone Cell Phone</p><p>Current School</p><p>Dates of Attendance Expected Graduation Date</p><p>Class Year to be entered in Fall 2016 Junior Senior Masters </p><p>Field of Study/Major</p><p>Plans after Graduation (It’s OK if you don’t know)</p><p>How did you hear about this internship opportunity?</p><p>Gender Male Female </p><p>Ethnicity (Check all that apply) You must be from an under-represented group in STEM to be eligible for this program Black/African American Latino/Latina Native American/Alaskan Pacific Islander Filipino Other If chose “other” please specify</p><p>Do you have any disabilities or special needs? Yes No If yes, please explain</p><p>Will you be the first in your family to graduate from college? Yes No First Name Last Name</p><p>E-mail Address</p><p>List all relevant coursework that you have completed or are currently taking.</p><p>Please describe your experience working with computers. If you have programming skills, please be specific.</p><p>Do you have experience working with technical equipment or tools? This includes lab equipment as well as shop equipment. Please be specific.</p><p>Please give a brief description of your work experience. We are interested in ALL kinds of jobs, including non-scientific and unpaid (volunteer) work. You may attach a resume.</p><p>Please list the person you have asked to write a letter of recommendation. Send one letter only. Sending more than one letter will not increase your chances of being selected. </p><p>Using the project list provided, please identify five or six projects at UC Santa Barbara that interest you. Please include the name of the project and the name(s) of the project leader(s). This will help us place you in a lab that matches your interest. </p><p>1. 2. 3. 4. 5. 6.</p><p>Certification By initialing below, I certify that the responses on this application are true and correct.</p><p>Initials Date</p>