Louisiana State University Department of Geology& Geophysics GEOL 3666 Field Camp Scholarship Application 2011 This is an application for scholarship support for the LSU Geology course GEOL 3666 (Field Camp), 2011 session. The dates of the session are June 5 – July 17, 2011. Other scholarships must be applied for separately, despite any similarities between forms. The information provided by you on this form serves only as a basis for a Field Camp Scholarship award and is otherwise held confidential. Return the completed form to the student coordinator (address on reverse) by March 15, 2011 Please Print or Fill in Electronically Name______________________________________ Student ID# (non-LSU leave blank) _____________________________ Mailing Address ________________________________________________________________________________________ Number, Apt. #, Street ______________________________________________________________________________________________________ City State Zip Code Parish (County) Telephone (______)__________________ (______)___________________ e-mail __________________________________ University/College in which you are currently enrolled:
LSU
Other _____________________________________________________ Your classification during Spring 11 semester (Fresh., Soph., etc):____________________ Fall 10:______________________ Anticipated date of Graduation: ________________
Cumulative GPA (end of Fall 10): _____________
Name and e-mail of two references. Include at least one university course professor or academic supervisor. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Is your parent or grandparent a current/past member of LSU faculty or staff? ______Yes______No If yes, provide the following information: FULL NAME DEPARTMENT OF EMPLOYMENT
JOB TITLE
___________________________________________________________________________________ ___________________________________________________________________________________ List all scholarships, grants, fellowships, and assistantships (and their dollar amounts) you have received while a university student. Indicate those which can apply to expenses related to the Field Camp for which you are applying. Clearly state if none of your financial awards can be applied to Field Camp 2011. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________
List activities, organizations, leadership roles, honors, community involvement, etc. in which you have participated or are currently participating. If you have a current résumé, please include it.
Have you ever been formally charged with a violation (other than parking or traffic fine) of: State or Federal law City or Parish/County law or ordinance University code (including academic dishonesty)
Yes Yes Yes
No No No
If ‘Yes’ to any of the above, explain the situation (date, location, jurisdiction, incident particulars) and the present status or outcome of the case:
Your signature certifies that all information presented on this application is true and complete.
_______________________________________________________________________ Signature Return this completed application by March 15 to: Heather Lee Field Camp Student Coordinator Dept. of Geology & Geophysics E-235 Howe-Russell Louisiana State University Baton Rouge, LA 70803
Date