This application can not be saved for future use, you must fill it out completely before submission to AHETEMS. Feel free to print this page now and work on the application at your leisure. If you have any questions, please see the AHETEMS website for more information.

A. Personal And Background Information
*Name	firstmilast
*Gender:	Male Female
Student Permanent Home Address
*E-Mail Address:
*Telephone:
*Address:
Address 2:
*City , *State   *ZIP	city Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming statezip
*County	-- Select County -- (select state first)
*Congressional District:
	Click here for help finding your congressional district.
Student Mailing Address at University (if different from above)
E-Mail Address:
Telephone:
Address:
Address 2:
*City , *State   *ZIP	city Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia 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 Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming statezip
* Race/Ethnicity
Central American Cuban Dominican Mexican American Puerto Rican South American Spanish White/Anglo Black/African American Asian/Pacific Islander   Native American/American Indian   --  Tribal Affiliation Other
Residency
*Citizenship Status:	U.S. Citizen Permanent Resident Temporary Resident (F1 Visa Student)
*SSN/EID or Visa No:
Visa Expiration Date:
Parental/Sibling Education
*Mothers Highest Educational Attainment No formal education Less than 8th grade Some high school HS Diploma GED Some college Associates degree Bachelors degree Masters degree Doctorate/Professional I do not know Not applicable
*Fathers Highest Educational Attainment No formal education Less than 8th grade Some high school HS Diploma GED Some college Associates degree Bachelors degree Masters degree Doctorate/Professional I do not know Not applicable
*Some of my brothers/sisters are attending/attended college?:	Yes No I do not have any siblings
*Some of my brothers/sisters have received a bachelor's degree?:	Yes No I do not have any siblings

B. Academic Information
*I am a:	Undergraduate Student Graduate Student
Undergraduate Students
*Classification:	Freshman Sophomore Junior Senior
*College/University	Select University
*Major Field of Study:
Minor Field of Study:
*Credit Hours Completed:
*GPA (On a 4.0 Scale):
*Expected Graduation Date:
*Did you transfer from a community college?:	Yes No
If you are attending a community college, do you intend to transfer to a 4-year college or university?:	Yes No
If yes, which college/university?	Select University
Including the current year, how many years did you attend a community college?:
If you have previously received a SHPE scholarship, please enter when:
Graduate Students
*Classification:	Masters
*College/University	Select University
*Major Field of Study:
Minor Field of Study:
*Credit Hours Completed:
*GPA (On a 4.0 Scale):
*Expected Graduation Date:
If you have previously received a SHPE scholarship, please enter when:

C. SHPE Background
*Are you a SHPE member?:	Yes No
*I have been a SHPE member for at least Less than 3 months 3 months 6 months 12 months 2 years 3 years 4 years 5 years More than 5 years
How many years have you held a leadership position in SHPE:
How many times have you presented a technical paper or research poster or competed in the design competition at the SHPE Conference:

* D. Personal Statement

Please include a succinct personal statement of at least 250 words that uniquely addresses why you are interested in working with CDM. Please include as much information on your backgrund as possible. Include such elements as challenges you have overcome, family background, community involvement, leadership, academic achievement(s), research/internship/co-op experience(s), and short-term and long-term goal(s) and aspiration(s). Be sure to include any information you feel the scholarship review committee should consider when reviewing your application.

* E. Site Locations
*Indicate the first preference office location you would like to work at:	Select Site Cambridge, MA Chicago, IL Dallas, TX Denver, CO Edison, NJ Falls Church, VA Irvine, CA Orlando, FL Phoenix, AZ
*Indicate the second preference office location you would like to work at:	Select Site Cambridge, MA Chicago, IL Dallas, TX Denver, CO Edison, NJ Falls Church, VA Irvine, CA Orlando, FL Phoenix, AZ

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