2009 CTIO Research Experiences for Undergraduates Program
APPLICATION FORM
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Personal Information
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Name: _____ Vader, Darth ___________________________________________
Last First Middle
Mailing address as of October 8, 2003:
Street: ___ 123 Mystreet Blvd. _________________________________________
City, State, Zip: ___ Gotham City, XX 90210 ____________________________
List telephone numbers and electronic mail addresses where you
can be reached between now and 31 December 2003. Include the
location (dorm, office, home, etc.)
(Area Code) Telephone # City & State Location
___ (000) 000-0000 _____________ Gotham City, XX ______ Dorm room ______
___ (000) 000-0000 _____________ Gotham City, XX ______ Office _________
___ (000) 000-0000 _____________ Smallville, YY _______ Parents' house _
Primary Email address: ___ dhoard@noao.edu ___________
Alternate Email Address: ___ batcave@yahoo.com _________
Home/Permanent Address (if different from above)
Street: ___ 456 Kentfarm Rd. ___________________________________________
City, State, Zip: ___ Smallville, YY 12345 ____________________________
Date of Birth: ___ 4 July 1776 _______________ Sex: F_____ M__XX__
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Educational Information
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School you presently attend: ___ Gotham University _____________________
Location (City, State, Zip): ___ Gotham City, XX 90210 _________________
Current Academic Status
____ Freshman ____ Sophomore _XX_ Junior ____ Senior
____ Other - Explain: __________________________________________________
Planned Status as of 12 January 2004
(Note that you MUST be an undergraduate student during the CTIO REU
program - you CANNOT have received your degree before the end of the program)
____ Freshman ____ Sophomore _XX_ Junior ____ Senior
____ Other - Explain: __________________________________________________
College Major: ___ Astronomy ___________ Minor: ___ Leisure Studies ____
Grade Point Averages: (either letter grade or 4.0 pt scale):
Cumulative/Overall: _ 3.80 _
Science & Math courses: _ 3.92 _
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Experience
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SCIENTIFIC WORK EXPERIENCE SUMMARY:
List any scientific or related employment, including research
positions, which you have had since graduating from high school.
NOTE: On a separate sheet, provide a short description (not more
than one paragraph) of each job or project.
Dates: From - To Employer's Name Employer's Phone #
Sep 2001 - Jun 2002 ____ Dr. L. Luthor ________ (000) 000-0000 __________
Sep 2002 - present _____ Dr. B. Wayne _________ (000) 000-0000 __________
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List other work experience:
Jul - Aug 2002: Photographer for the Daily Bugle, supervisor Mr. J. J. Jameson
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List experience with computers, operating systems, computer languages,
and major software systems (e.g., IRAF, AIPS, PROS, VISTA).
___ Experience with Windows and Unix operating systems
___ Programming experience with FORTRAN and IDL
___ Experience with IRAF on Linux
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Other Information
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Please check one: _XX_ United States Citizen
____ Permanent Resident of the United States
Do you speak Spanish? (please check one)
(Note: knowledge of Spanish is NOT a requirement, but your answer
will help us plan the program.)
____ Fluently ____ Moderately well _XX_ A little ____ Not at all
How did you learn about the CTIO REU program?
____ Poster _XX__ Professor (or other school offical) ____ Web page
____ Other: _________________________________________________________
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Letters of Recommendation/References
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Indicate who will send letters of recommendation.
Name E-mail address Phone
Address City, State, Zip
1) ___ Dr. L. Luthor _____ lex@metropolis.edu ____ (000) 000-0000 _______
___ University of Metropolis, Dept. of Physics, Metropolis, ZZ, 09876
2) ___ Dr. B. Wayne ______ bman@u.gotham.edu _____ (000) 000-0000 _______
___ Gotham University, Dept. of Astronomy, Gotham City, XX, 90210
3) ___ Dr. P. Parker _____ webhead@u.gotham.edu __ (000) 000-0000 _______
___ Gotham University, Dept. of Chemistry, Gotham City, XX, 90210
SIGNATURE: _________________________________________ DATE: _____________