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Biomolecular Research Center
NSF S-STEM Scholar Information and Release Form
NSF S-STEM Scholar Information and Release Form
Name
*
Required
First
Last
Date of Birth
- must be mm/dd/yyyy format
*
Required
MM slash DD slash YYYY
Email
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Required
Permanent Address:
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Required
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
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Florida
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Maryland
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Montana
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North Carolina
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Northern Mariana Islands
Ohio
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Pennsylvania
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Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
School Residential Address (if different from above):
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Demographic Information:
Gender (check only one):
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Required
Male
Female
Do not wish to provide
Ethnicity (check only one):
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Required
Hispanic or Latino
Not Hispanic or Latino
Do not wish to provide
Race (check all that apply):
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Required
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Do not wish to provide
Disability (check only one):
*
Required
• Deaf or serious difficulty hearing • Blind or serious difficulty seeing even when wearing glasses • Serious difficulty walking or climbing stairs • Other serious disability related to a physical, mental, or emotional condition
No
Do not wish to provide
Yes (check yes if any of the following apply)
Intended Major at BOISE STATE UNIVERSITY (check only one):
*
Required
Astronomy
Biological Sciences
Biology
Biotechnology
Chemistry
Computer Information Science
Computer Science
Computers
Engineering – Aerospace
Engineering – Biological
Engineering – Biomedical
Engineering – Chemical
Engineering – Civil
Engineering – Computer
Engineering – Electrical
Engineering – Industrial
Engineering – Mechanical
Engineering – Nuclear
Engineering – Petroleum
Engineering – Technology
Engineering (general)
Environmental Sciences
Geosciences
Materials Science
Mathematical Sciences
Mathematics
Physical Sciences
Physics
Technology – Chemical
Technology – Information
Technology – Manufacturing
Technology (general)
Degree Program (check only one):
*
Required
Associate’s
Bachelor’s
Master’s
Doctorate
Class (check only one):
*
Required
Freshman (<25 credits)
Sophomore (26 - 57 credits)
Junior (58 - 89 credits)
Senior (>90 credits)
Graduate Student
Do you work while enrolled in school?
*
Required
Yes
No
If you selected yes, how many hours on average per week during the term?
What is your career goal?
*
Required
Release of Information:
*
Required
By checking the box, I certify that the information contained in this form is true. I also give my permission for all information in this form as well as the relevant information in my BOISE STATE UNIVERSITY record, including transcript and entrance information, to be available to my S-STEM advisors for the purpose of reporting to NSF and determining continuing eligibility for this scholarship. I realize that NSF or its agents may contact me to request further information for the purposes of evaluation of the S-STEM program, but that I am not required to participate. I also understand that this form will become a part of my official student record at BOISE STATE UNIVERSITY.
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