Full name: Month/Day/Year of birth: / / Gender: Male Female Ethnicity (optional): African American American Indian/Alaska Native check all that apply Asian/Pacific Islander Hispanic White United States citizen: Yes No Email address: Contact number: ( ) - Cell Home Office Other Mailing address: Name of college/university attending: Major: GPA (4 pt scale): Year of study: Freshman Sophmore Junior Senior Expected date of graduation: / / Research interest: Materials for Health Materials for Energy choose one Materials for the Environment Top three REU summer advisor selections (ranked) based on choices from website: 1) 3) 2) Recommender’s name and email address: