Application form the timbuktu academy



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APPLICATION FORM

THE TIMBUKTU ACADEMY

Southern University and A&M College

(All fields must be fully completed.)


Diola Bagayoko, Ph.D., Director

T
SUMMER BRIDGE INSTITUTE (SBI)

Undergraduate Research Program (URP)



(Check one or both)
imbuktu Academy

Southern University and A & M College

P. O. Box 11776 - Baton Rouge, LA 70813

Phone: (225) 771-2730 Fax: (225) 771-4341

e-mail: timbuktu.academy@grant.phys.subr.edu


PERSONAL DATA

Name (last, first, middle):




Social Security No.:




E-mail Address (Important):




Date of Birth:





Mailing Address:




City:




State:



Zip Code:





Home Phone:


( )




*Specify Gender:


Male Female





Permanent Address (if different from above)




City



State




Zip Code




Permanent Contact Phone Number


( )

























*Ethnicity (Check all that apply.):




African American




Asian American




Hispanic American




























Native American




White American/Caucasian




Other _____________

*This optional information has no bearing on the selection process. It is strictly for statistical purposes.






















Citizenship




U. S.




Permanent Resident




Other

(MUST BE A U.S. CITIZEN OR PERMANENT RESIDENT)


EDUCATION RECORD

High School (2000-2001):






Expected Graduation Date:



GPA:




(ATTACH A COPY OF AN OFFICIAL HIGH SCHOOL TRANSCRIPT)

(Intended) Major:






Current Grade

 HS-Sr.

 CO-Fr.

 CO-So.

 CO-Jr.  CO-Sr.


LEGEND: HS- High School * CO - College * Sr. - Senior * Fr. -Freshman * So.- Sophomore * Jr. - Junior

PARENT/GUARDIAN INFORMATION




MOTHER













Name

Address (if different from above)

Daytime Phone Number













FATHER













Name

Address (if different from above)

Daytime Phone Number




Highest grade completed by

MOTHER




FATHER








ACT SCORES: Composite: _______
English: ________ Math: _______
Reading: _______ Sci. Reas. _____
SAT: Verbal _______ Math ______

MAIL COMPLETED APPLICATIONS TO:
Dr. Diola Bagayoko

Director, Timbuktu Academy

P. O. Box 11776

Baton Rouge, LA 70813




FOR OFFICE USE ONLY:
Date Received: _________________
Status: ________________________
Letter:_________________________


APPLICATION DEADLINE: MARCH 30, 2003 for SBI, Applications are accepted year round for URP









Student's Signature




Parent's Signature








Date




Date




APPLICATIONS ARE DEEMED INCOMPLETE UNLESS ACCOMPANIED BY A SHORT ESSAY, THREE LETTERS OF RECOMMENDATION, ACT/SAT SCORE REPORT, RESUME AND AN OFFICIAL HIGH SCHOOL TRANSCRIPT.

FUNDED BY THE DEPARTMENT OF THE NAVY, OFFICE OF NAVAL RESEARCH (ONR) - Page 1 of 2

SBI/URP APPLICATION


Page 2

REFERENCES

Please list below the name, title/affiliation, and office phone number of the three (3) individuals you have asked to write a letter of recommendation. NOTE: INDIVIDUALS MUST BE HIGH SCHOOL OR COLLEGE SCIENCE, ENGLISH, MATHEMATICS, OR ENGINEERING TEACHERS/INSTRUCTORS.













Name

Title

Telephone



Name

Title

Telephone



Name

Title

Telephone









ESSAY









On a separate sheet, please describe your career goals, interest in science, and previous science experiences (science fairs/rallies, summer research, summer enrichment, etc., if any.












CHECK LIST


This application must have the following documents attached:








  1. Official high school transcript

  2. Three letters of recommendation

  3. Essay (See Section Above)

  4. ACT/SAT score report (all pages)

  5. Resume' (See sample resume' at our website http://www.phys.subr.edu/timbuktu.htm)

  6. SUBR Admissions application, if not previously submitted (for SBI applicants only)


APPLICATION DEADLINE: MARCH 30, 2003 for SBI
The application and addition information on the Timbuktu Academy may also be obtained via the home page of the Timbuktu Academy:

http://www.phys.subr.edu/timbuktu.htm



















APPLICATIONS ARE DEEMED INCOMPLETE UNLESS ACCOMPANIED BY A SHORT ESSAY, THREE LETTERS OF RECOMMENDATION, ACT/SAT SCORE REPORT, RESUME AND AN OFFICIAL HIGH SCHOOL TRANSCRIPT.


FUNDED BY THE DEPARTMENT OF THE NAVY, OFFICE OF NAVAL RESEARCH (ONR)



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