LERCIP Application

* Required

()
Personal Information

Full legal
name is requested
*First Name: *Middle Initial:
*Last Name:

*Birth Info

*Birth Date:
(mm/dd/yyyy)
*Birth City:
*Birth State:

AK AL AR AZ CA
CO CT DC DE FL
GA HI IA ID IL
IN KS KY LA MA
MD ME MI MN MO
MS MT NC ND NE
NH NJ NM NV NY
OH OK OR PA PR
RI SC SD TN TX
UT VA VT WA WI
WV WY

*Birth Country:

United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina
Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana
Bouvet Island Brazil
British Indian Ocean Territory Brunei Darussalam Bulgaria
Burkina Faso Burundi
Cambodia Cameroon
Canada Cape Verde
Cayman Islands Central
African Chad Chile China Christmas Island Cocos (Keeling)
Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic
East Timor T Ecuador
Egypt El Salvador
Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands
(Malvinas) Faroe Islands Fiji Finland France French Guiana French Metropolitan French
Polynesia French Southern Territories
Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island & Mcdonald Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Iraq Ireland Israel Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South
Kuwait Kyrgyzstan
Lao People'S Democratic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Moldova, Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles
New Caledonia New
Zealand Nicaragua Niger Nigeria Niue Norfolk Northern Mariana Islands Norway
Oman Pakistan Palau Palestinian Authority
Panama Papua New Guinea
Paraguay Peru Philippines Pitcairn Poland Portugal Qatar Reunion Romania Russia Russian Federation Rwanda
Sahara Saint Helena
Saint Kitts And Nevis Saint
Lucia Saint Pierre And Miquelon Saint Vincent Samoa San Marino Sao Tome And Principe
Saudi Arabia Senegal
Serbia Seychelles
Sierra Leone Singapore
Slovakia (Slovak Republic) Slovenia Solomon Somalia South Africa Spain Sri Lanka Sudan Suriname Svalbard And Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic
Taiwan, Tajikistan
Tanzania, Thailand
Togo Tokelau Tonga Trinidad And Tobago
Tunisia Turkey Turkmenistan Turks And Caicos
Islands Tuvalu Uganda Ukraine United Arab Emirates United
Kingdom United States United States Minor Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy
See) Venezuela Viet
Nam Virgin Virgin
Islands Wallis And Futuna Islands Yemen Yugoslavia Zaire Zambia Zimbabwe

*US Citizen (citizenship will be verified prior to hire)

*Permanent Address: (Home Address)

Prior to
April 15 send mail to this address

After
April 15 send mail to this address

*Street:

*City:

*State:

AK AL AR
AZ CA CO CT DC
DE FL GA HI IA
ID IL IN KS KY
LA MA MD ME MI
MN MO MS MT NC
ND NE NH NJ NM
NV NY OH OK OR
PA PR RI SC SD
TN TX UT VA VT
WA WI WV WY

*Zip Code:

-

*Temporary Address: (while living at school)

Prior to April 15 send mail to this address

After April 15 send mail to this address

*Street:

*City:

*State:

AK AL AR
AZ CA CO CT DC
DE FL GA HI IA
ID IL IN KS KY
LA MA MD ME MI
MN MO MS MT NC
ND NE NH NJ NM
NV NY OH OK OR
PA PR RI SC SD
TN TX UT VA VT
WA WI WV WY

*Zip Code:

-

Contact Info:

*Home Phone:

*Mobile Phone:

*Alt. Phone:

*FAX:

*Primary E-Mail:

*Alt. E-Mail:

()
Academic Information

*College or University (currently attending or plan to
attend)

School
Name:

Alabama A & M University
Arkansas State University Baldwin
Wallace College Baylor University Bowling Green State University California
State University - Long Beach Carnegie Mellon
University Case Western Reserve University
Centre College City College of New
York Cleveland State University Colorado State University Cornell
University Cuyahoga Community College
Denison University Duquesne
University Embry-Riddle Aeronautical
University Florida Institute of Technology
Florida International University Georgia Institute of Technology High Point
University Hiram College Illinois Institute of Technology Interamerican University of Puerto Rico - Bayamon Iowa State University John Carroll
University Kent State University Kettering University Lehigh
University Lorain County Community College
Massachusetts Institute of Technology Mercy College Miami University
Mount Union College New Jersey
Institute of Technology North Carolina Agricultural
& Technical State University Northwestern
University Ohio Northern University Ohio State University Ohio
University Pennsylvania State University
Pennsylvania State University - Erie Purdue University Purdue University -
Calumet Rensselaer Polytechnic Institute
Rochester Institute of Technology Rose-Hulman Institute of Technology Smith
College Southern Illinois University
Carbondale Syracuse University Tennessee State University Texas Tech
University Tri-State University Universidad Del Turabo University of
Akron University of Alaska University of Central Oklahoma University
of Cincinnati University of Dayton University of Detroit Mercy University of
Kentucky University of Maine University of Maryland University of
Michigan University of Missouri - St. Louis
University of New Mexico University
of North Carolina - Pembroke University of Notre
Dame University of Pittsburgh University of Pittsburgh - Johnstown University of Puerto Rico - Mayaguez University of Puerto Rico - Rio Piedras University of South Florida University of
Texas - Arlington University of Texas -
Austin University of Texas - El Paso
University of Toledo University of
West Georgia Washington University Wayne State University West Virginia
University Western Michigan University
Wichita State University Wilberforce University Wright State
University

If not found,
enter here:

City:

State:

AK AL AR AZ CA
CO CT DC DE FL
GA HI IA ID IL
IN KS KY LA MA
MD ME MI MN MO
MS MT NC ND NE
NH NJ NM NV NY
OH OK OR PA PR
RI SC SD TN TX
UT VA VT WA WI
WV WY

Zip Code:

-

*Academic level at start of next school year:

College Freshman College Sophomore
College Junior College
Senior Master Student Ph.D.
Student H.S. Seniors select College Freshman

*Credit hours earned by the end of this school year:

*Total Credit hours required for graduation:

*Planned graduation date (mm/dd/yyyy):

(mm/dd/yyyy)

*Cumulative GPA out of 4.0:

(must be supported by school
transcripts; min 3.0, max 4.0)

*Degree level currently pursuing:

B.A. B.S. M.S. M.S./M.S. Ph.D.

*Major 1:

Accounting
Aeronautical Engineering Aerospace Aerospace Engineering
Anthropology Applied
Mathematics Applied Physics Architectural Engineering Architecture/
Environmental Design Astronautical
Engineering Astronomy Astrophysics Athletic Training
Aviation Science Aviation Science
Management Bioengineering Biology Biomedical Engineering
Business Business
Administration Business Administration -
Accounting Business Administration - IT
Business Finance Business
Management Ceramic Engineering Chemical Engineering Chemistry
Civil Engineering Communications Computer
Engineering Computer Science Computerized Information Systems Economics Education Electric Power Engineering Electrical
Engineering Electrical Engineering
Technology Electronic And Computer
Technology Engineering Engineering Management (Manufacturing) Engineering Physics Engineering
Science English Environmental Engineering Environmental
Geology Environmental Studies Envitomental Science Exploration Health
Sciences Finance French German Hispanic Studies Human Factors
Human Resource Management Imaging
And Photographic Technology Industrial
Engineering Information Architecture
Information Sciences and Systems Information Technology International
Business Journalism Labor
Relations Management Manufacturing Engineering Materials
Engineering Materials Science Mathematics Mechanical Engineering
Mechatronics Engineering Media
Management Metallurgical Engineering
Microbiology and Cell Science Microbiology and Cell Science Microbiology and Cell Science Microbiology and Cell Science Microbiology and Cell Science Minor in
Applied Mathematics New Media Publishing
Nuclear Engineering Nutrition
Science Office Administration Operations Management Physics
Polymer Engineering Psychology Public Administration
Public Policy And Management Quality Assurance Safety and
Environmental Management Security And Intelligence
Studies Social And Public Policy Spanish Minor Systems
Engineering TV/Digital Film Visual Communication Technology

If not found, enter here:

*Major 2:

Accounting
Aeronautical Engineering Aerospace Aerospace Engineering
Anthropology Applied
Mathematics Applied Physics Architectural Engineering Architecture/
Environmental Design Astronautical
Engineering Astronomy Astrophysics Athletic Training
Aviation Science Aviation Science
Management Bioengineering Biology Biomedical Engineering
Business Business
Administration Business Administration -
Accounting Business Administration - IT
Business Finance Business
Management Ceramic Engineering Chemical Engineering Chemistry
Civil Engineering Communications Computer
Engineering Computer Science Computerized Information Systems Economics Education Electric Power Engineering Electrical
Engineering Electrical Engineering
Technology Electronic And Computer
Technology Engineering Engineering Management (Manufacturing) Engineering Physics Engineering
Science English Environmental Engineering Environmental
Geology Environmental Studies Envitomental Science Exploration Health
Sciences Finance French German Hispanic Studies Human Factors
Human Resource Management Imaging
And Photographic Technology Industrial
Engineering Information Architecture
Information Sciences and Systems Information Technology International
Business Journalism Labor
Relations Management Manufacturing Engineering Materials
Engineering Materials Science Mathematics Mechanical Engineering
Mechatronics Engineering Media
Management Metallurgical Engineering
Microbiology and Cell Science Microbiology and Cell Science Microbiology and Cell Science Microbiology and Cell Science Microbiology and Cell Science Minor in
Applied Mathematics New Media Publishing
Nuclear Engineering Nutrition
Science Office Administration Operations Management Physics
Polymer Engineering Psychology Public Administration
Public Policy And Management Quality Assurance Safety and
Environmental Management Security And Intelligence
Studies Social And Public Policy Spanish Minor Systems
Engineering TV/Digital Film Visual Communication Technology

If not found, enter here:

*Major 3:

Accounting
Aeronautical Engineering Aerospace Aerospace Engineering
Anthropology Applied
Mathematics Applied Physics Architectural Engineering Architecture/
Environmental Design Astronautical
Engineering Astronomy Astrophysics Athletic Training
Aviation Science Aviation Science
Management Bioengineering Biology Biomedical Engineering
Business Business
Administration Business Administration -
Accounting Business Administration - IT
Business Finance Business
Management Ceramic Engineering Chemical Engineering Chemistry
Civil Engineering Communications Computer
Engineering Computer Science Computerized Information Systems Economics Education Electric Power Engineering Electrical
Engineering Electrical Engineering
Technology Electronic And Computer
Technology Engineering Engineering Management (Manufacturing) Engineering Physics Engineering
Science English Environmental Engineering Environmental
Geology Environmental Studies Envitomental Science Exploration Health
Sciences Finance French German Hispanic Studies Human Factors
Human Resource Management Imaging
And Photographic Technology Industrial
Engineering Information Architecture
Information Sciences and Systems Information Technology International
Business Journalism Labor
Relations Management Manufacturing Engineering Materials
Engineering Materials Science Mathematics Mechanical Engineering
Mechatronics Engineering Media
Management Metallurgical Engineering
Microbiology and Cell Science Microbiology and Cell Science Microbiology and Cell Science Microbiology and Cell Science Microbiology and Cell Science Minor in
Applied Mathematics New Media Publishing
Nuclear Engineering Nutrition
Science Office Administration Operations Management Physics
Polymer Engineering Psychology Public Administration
Public Policy And Management Quality Assurance Safety and
Environmental Management Security And Intelligence
Studies Social And Public Policy Spanish Minor Systems
Engineering TV/Digital Film Visual Communication Technology

If not found, enter here:

If currently in college and planning to attend a different
college/univ next Fall, please indicate reason and name of college/university
below:

Reason for changing college/university: Transfer Student Graduating Senior
First Year Graduate Student Ph.D.
Student

School
Name:

Alabama A & M University Arkansas State
University Baldwin Wallace College Baylor University Bowling Green State
University California State University - Long
Beach Carnegie Mellon University Case Western Reserve University Centre
College City College of New York Cleveland State University Colorado State
University Cornell University Cuyahoga Community College Denison
University Duquesne University Embry-Riddle Aeronautical University Florida Institute of Technology Florida
International University Georgia Institute of
Technology High Point University Hiram College Illinois Institute of
Technology Interamerican University of Puerto Rico -
Bayamon Iowa State University John Carroll University Kent State
University Kettering University Lehigh University Lorain County Community
College Massachusetts Institute of
Technology Mercy College Miami University Mount Union
College New Jersey Institute of Technology
North Carolina Agricultural & Technical State
University Northwestern University Ohio Northern University Ohio State
University Ohio University Pennsylvania State University Pennsylvania
State University - Erie Purdue University
Purdue University - Calumet Rensselaer Polytechnic Institute Rochester
Institute of Technology Rose-Hulman Institute of
Technology Smith College Southern Illinois University Carbondale Syracuse University Tennessee State
University Texas Tech University Tri-State University Universidad Del
Turabo University of Akron University of Alaska University of Central
Oklahoma University of Cincinnati University of Dayton University of Detroit
Mercy University of Kentucky University of Maine University of
Maryland University of Michigan University of Missouri - St. Louis University of New Mexico University of
North Carolina - Pembroke University of Notre
Dame University of Pittsburgh University of Pittsburgh - Johnstown University of Puerto Rico - Mayaguez University of Puerto Rico - Rio Piedras University of South Florida University of
Texas - Arlington University of Texas -
Austin University of Texas - El Paso
University of Toledo University of
West Georgia Washington University Wayne State University West Virginia
University Western Michigan University
Wichita State University Wilberforce University Wright State
University

If not
found, enter here:

City:

State:

AK AL
AR AZ CA CO CT
DC DE FL GA HI
IA ID IL IN KS
KY LA MA MD ME
MI MN MO MS MT
NC ND NE NH NJ
NM NV NY OH OK
OR PA PR RI SC
SD TN TX UT VA
VT WA WI WV WY

Zip
Code:

-

Please list
winter/spring courses for current school year:

()
Placement Information

Placement Information:

Please indicate
the discipline in which you would like to intern if positions are available.
Final student placement is determined by mentor's assignment requests. No
internships in Medicine or Veterinary Medicine are offered.

First choice:
Accounting Aero/Astro Engineering Biological
Science Biomedical Science Business Adm. Ceramics Chemical Eng. Chemistry Computer Eng. Computer Science
Education Electrical Eng.
Environmental Eng./Science Graphics Life Science Materials Eng. Mathematics Mechanical Eng. Metallurgy Optics Personnel Physical Science Polymers Procurement Structural Eng.
Systems Eng.
Second
choice: Accounting Aero/Astro Engineering
Biological Science Biomedical
Science Business Adm. Ceramics Chemical Eng. Chemistry Computer Eng. Computer Science Education Electrical Eng. Environmental
Eng./Science Graphics Life
Science Materials Eng. Mathematics Mechanical Eng.
Metallurgy Optics Personnel Physical Science Polymers Procurement Structural Eng. Systems
Eng.
Third choice:
Accounting Aero/Astro Engineering Biological
Science Biomedical Science Business Adm. Ceramics Chemical Eng. Chemistry Computer Eng. Computer Science
Education Electrical Eng.
Environmental Eng./Science Graphics Life Science Materials Eng. Mathematics Mechanical Eng. Metallurgy Optics Personnel Physical Science Polymers Procurement Structural Eng.
Systems Eng.
Other discipline if not
listed (be specific):
Select which session
you prefer: May 18 -
Jul 25 Jun 01 - Aug 08 Jun
08 - Aug 15
If you were a previous LERCIP participant would you like to
return to the same organization and mentor? No Yes

If
yes, you are encouraged to contact the mentor and let him/her know that you have
applied for the program and if summer positions are available in his/her
respective organization, you would like to be considered. Remember there is no
GUARANTEE of a position, as organizational, budgetary and staff needs change
each year.

If
you have a relative who works for NASA or NASA contractor please provide the
following information:
Name of Relative:

Relationship to you:
Company
name/area/organization:

*What do you hope to gain from participating in this
program?:

You have characters left.

*How might this experience help you in your chosen field
of study/future career?:

You have characters left.

*Describe any related activities that reflect your
commitment to your major (e.g. internships, memberships in related
organizations, related skills, etc.):

You have characters left.

*Attach Resume:

(Microsoft Word .doc or Adobe Acrobat .pdf formats only)

Please indicate any NASA program you previously
APPLIED for or PARTICIPATED in:

Applied

Participated

Year

Applied

Participated

Year

GRC Engineering Technology

GRC N.A.S.A. Project

GRC Exploring

GRC Shadowing

GRC High School

GRC TSU Collegebound

GRC LERCIP College

FIRST

GRC LERCIP Scholars

NASA SHARP

GRC NASA Plus

SEMAA

Other NASA or Internship programs:

Involvement with other NASA
programs not listed or other Non-NASA Internship Programs. Please include name
of program and dates of participation.

You have characters left.

If selected,do you need to be provided with the program's
short-term housing list?: No Yes

Would you like your name and email sent to selected
students interested in shared housing?:
No Yes

()
Certification

Certification

I certify, by entering my name below, that I am a citizen of the United
States of America and that all information contained in this application is
accurate and correct. I further understand and agree that any misrepresentation
or inaccurate information reported on my application will be cause for
disqualification for consideration and from participation in LERCIP and other
NASA and OAI programs. If selected to participate, I understand I must
participate for the full duration of the program and failure to do so or abide
by the program policies and requirements, safety and security policies, and
completion of required program forms will result in the immediate termination of
my internship and will be just cause for disqualification or consideration from
future participation in LERCIP and other NASA and OAI programs.

I
understand and acknowledge that participation in the program does not
entitle me to unemployment compensation. Type your full name below to
acknowledge your acceptance.

*Student full name:

If under 18 years of age, parent or guardian name must
also be provided below:

*Parent/Guardian full name:

()
Optional Information

Optional Information

In order to determine the degree to which members of each
ethnic and racial group are reached by this announcement, NASA requests that the
student select the appropriate responses below. Submission of this information
is VOLUNTARY. The information solicited on the form will not be available
to those responsible for reviewing applications, but will be used by OAI and
NASA primarily to determine the extent to which various populations are
represented in the applicant pool. This information is strictly
confidential.

*Gender:

Female Male

*Race/National Origin:

American Indian or Alaska native
(Non-Hispanic) Asian (Non-Hispanic) Black or African-American Indian (Non-Hispanic) Hispanic/Latino(a) Native American or Pacific
Islander (Non-Hispanic) Two or more races
White (Non-Hispanic)

Individual with
disability*

Please list any
special accommodations required:

You have characters left.

* A person having a physical or mental impairment that
substantially limits one or more major life activities, has a record of such
impairment, or is regarded as having such impairment.

Author: GRC W-ADE Team
NASA Official:
[email-masked]

NASA Privacy
Statement, Disclaimer & Accessibility Certification
Last
Updated: January 12, 2009