* Name:

* Summer Address:
Address 2:

* City, State, ZIP:

* Phone:

* Email address:

In am interested in majoring in the following areas:
 Computer Science
 Engineering
 Mathematics

* Birthdate:

* High School Name:

* High School Overall GPA:

* Gender:
 Female
 Male

* Ethnicity/Ethnicities:

* Citizenship:
 U.S. Citizen
 Permanent Resident: # A -

* Did either of your parents complete a 4-year college degree?
 Yes
 No

* Have you submitted a Free Application for Federal Student Aid (FAFSA)?
 Yes
 No

SAT:
Verbal Score:
Quantatative Score: OR

ACT Scores:
Overall:
Mathematics Subscore:

Participation in College and Pre-College Programs (check all that apply):
 EAOP
 MESA
 Talent Search
 Upward Bound
 Cal-SOAP
 AVID
 EOPS
 SSS
 CAMP
 MEP
 Hughes
 MARC/MBRS
 GEARUP
 JOM
 EYH
Other:

1. * Describe any projects you have completed for school and/or fun (e.g. science fair, math contests, programming, etc.)
   
2. * List honors, awards, prizes or recognition you have received during the past three years.
   
3. * List school, extracurricular and community activities you have participated in during the past three years.
   
4. * List employment/work study positions you have held during the past three years.
   

List one teacher or employer or other mentor who is not related to you, from whom you have requested a letter of recommendation. This person should be familiar with your academic and/or professional work.

* Name:

* Phone Number:

* In 500 words or less, tell us who you are. What is important to you? What is interesting to you? What do you want to accomplish in your life? Where do you see yourself in 5 and 10 years? DREAM BIG! There are no right answers. Describe other interests, experiences and information which may aid the Scientific Leadership Scholars Selection Committee.