Project SEED - North Carolina
Application Form for 2006

Application Procedure: It is your responsibility to be certain that we receive all the necessary materials with your application on or before the application deadline. Your application will not be considered unless all materials are included with your application.

1. Please send a copy of your most recent official high school transcript; the transcript should include PSAT, SAT, or ACT test scores. Send it to:

   Project SEED
   CIIT-Centers for Health Research
   PO Box 12137
   Research Triangle Park, NC 27709-2137
   

2. Also, include a Teacher Evaluation Form from a current science teacher (preferably chemistry) familiar with your academic work.

3. You must submit this form electronically.

4. You must write an essay (250 words minimum).

5. Applications, transcripts, and recommendations must be postmarked on or before May 15, 2006.

Application Form

American Chemical Society's PROJECT S.E.E.D./R.E.A.P. Program

Social Security Number:	Name:
Address:	City:
State	Zip Code
County	Evening Telephone Number
Are You A U.S. Citizen?
If you're not a U.S. citizen, state your country, citizenship, and type of visa you hold.
Sex	Racial or Ethnic Origin
Grade	Religious Denomination (optional)
Date of Birth	Place of Birth
Area of Science Interest	Email address
Describe any disability of which you are aware.
Name of Parent or Guardian	Street address
City	State
County	Zipcode

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Name of High School	Street Address
City	State
Zipcode	County
Name of High School Counselor	Phone Number of High School Counselor

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PSAT Scores: Math/Verbal

SAT Scores: Math/Verbal

ACT Scores: Math/Verbal

Overall GPA:

Class Rank

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List academic honors, prizes, scholarships, or extra-curricular activities, hobbies and special interests. Indicate any leadership positions held.

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What are your plans for post graduate/professional training? Please indicate by checking off the following.

Graduate school to pursue Ph.D in science/engineering

Graduate School to pursue M.S. degree in science/engineering

Medical school

Other health professional program

Other

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List High School Science and Mathematics courses which you have completed and provide a numerical average for each course.
Number of Brothers	Number of Sisters
If you have any list all serious illnesses, chronic illnesses, and significant allergies
Describe how you've spent your last two summers.
Father's name(last, first, middle)	Is he living?
His occupation?

Father's Approximate Income Range - This information is required to insure program eligibility. Please check the appropriate financial income range.

0-$15,000
$16,000-$20,000
$21,000-$25,000
$26,000-$30,000
$31,000-$35,000
$36,000-$40,000
$41,000-$50,000
$50,000-$100,000

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Mother's Name(last, first, middle)	Is she living?
Her occupation

Mother's Approximate Income Range - This information is required to insure program eligibility. Please check the appropriate financial income range.

0-$15,000
$16,000-$20,000
$21,000-$25,000
$26,000-$30,000
$31,000-$35,000
$36,000-$40,000
$41,000-$50,000
$50,000-$100,000

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Write an essay (2-3 paragraphs) describing your interest in science and your career goals. Include a discussion of any research or science fair projects in which you have participated as high school student.

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How can this program benefit you? (please write approx. 250 words)

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I certify that all of the above statements are true.

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Once you have submitted your application, Kenneth Cutler, Project SEED Director, will contact you either by phone or by email.

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