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Name: Citrus ID #____________________________ Last First

Phone Number: _______________________ Preferred E-mail Address: ____ __

A complete application must have the following:

Completed and signed STEM3/Project Raise (CSUF) Application Form

Unofficial transcripts for all colleges you’ve attended

Student Educational Plan (SEP)

A print out of your current Financial Aid Award letter (find this on Wingspan)

I am applying for: □ STEM3 (Cal Poly Pomona) □ Project RAISE (CSUF) □ Both

Please read, mark the appropriate boxes to indicate your understanding, and sign the application:

□ I hereby certify to the best of my knowledge that all information submitted as a part of this application is

complete and correct. I understand that failure to disclose accurate information is grounds for immediate

termination from this program.

□ I understand that as a member of STEM3 and/or Project RAISE (CSUF) my name, program status, and

other educational information may be shared with the STEM3/RAISE teams at Citrus College, Cal Poly

Pomona, CSU Fullerton and an independent evaluator.

□ I understand that to remain eligible for the STEM3, and/or Project RAISE (CSUF) and the benefits that come

with participation, I need to meet continuing eligibility requirements including maintaining a current SEP and

attending campus STEM events.

□ I understand that if at any point I decide I do not wish to transfer to California State Polytechnic University,

Pomona or CSUF Fullerton I should immediately notify the appropriate staff at Citrus College.

□ I give my permission for my photograph to be used in project related materials.

Applicant’s Signature Date

Please return your completed application to Monica Hernandez or Dr. Marianne Smith in SS 172

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Contact Information

Name: Last First Middle

Are you an AB 540 student? □ Yes □ No Birthdate / / AB 540 status does not preclude you from participating in the program

Social Security# XXX-XX-

Permanent Address: (Street, City, State and Zip Code)

Preferred E-mail Address: Citrus E-mail Address:

Cell phone number: ( ) Alternate phone number: ( )

Academic Information

What student services have you participated in at Citrus College?

□ Clubs/Organizations/Student Government □ Supplemental Instruction □ DSP&S

□ STEM Counseling □ Math or Science Tutoring □ EOPS

□ Bridge to the Geosciences □ Summer Research Experience □ STEM Workshops

□ STEM TRiO SSS

Secondary School Status- Please indicate the year you obtained a high school diploma or GED

□ High School ____ □ GED □ Other

Last High School Attended: Name City

List all College(s) and University(ies) you have attended, with dates: Indicate if you have completed a degree

(a) # Units Completed

(b) # Units Completed

(c) # Units Completed

Degree □AS/AA □ BS/BA

Degree □AS/AA □ BS/BA

Degree □AS/AA □ BS/BA

What colleges or universities are you interested in transferring to:

1st

Choice

2nd

Choice

3rd

Choice

Number of college units completed at Citrus College to date (C or better):

Citrus Major: Overall GPA: Expected Transfer Date:

Do you plan to attend graduate school (Masters, Ph.D., M.D., PharmD, etc.)? □ Yes □ No

If “yes” to any, please indicate field of interest __________________________________________________

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Which majors at Cal Poly Pomona are of interest to you? (Please mark all that apply)

□ Aerospace Engineering, B.S.

□ Agricultural Science, B.S.

□ Animal Health Science, B.S.

□ Animal Science, B.S. - Animal Industries Management

□ Biology, B.S. - Botany

□ Biology, B.S. - General Biology

□ Biology, B.S. - Microbiology

□ Biology, B.S. - Zoology

□ Biotechnology, B.S.

□ Chemical Engineering, B.S.

□ Chemistry, B.S. - Biochemistry

□ Chemistry, B.S. - Chemistry

□ Chemistry, B.S. - Industrial Chemistry

□ Civil Engineering, B.S. - Environmental Engineering

□ Civil Engineering, B.S. - General Civil Engineering

□ Civil Engineering, B.S. - Geospatial Engineering

□ Computer Engineering, B.S

□ Computer Science, B.S

□ Construction Engineering Technology

□ Electrical Engineering, B.S.

□ Electronics and Computer Engineering Technology, B.S.

□ Engineering Technology, B.S.

□ Environmental Biology, B.S.

□ Food Science and Technology, B.S.

□ Foods and Nutrition, B.S.

□ Geology, B.S.

□ Industrial Engineering, B.S.

□ Manufacturing Engineering, B.S.

□ Mathematics, B.S. - Applied Mathematics/Statistics

□ Mathematics, B.S. - Secondary Teacher Prep/Pure Mathematics

□ Mechanical Engineering, B.S.

□ Physics, B.S.

□ Plant Science, B.S.

□ Science, Technology, and Society, B.A

Which majors at CSU Fullerton are of interest to you? (Please mark all that apply)

□ Biochemistry, B.S.

□ □ Computer Engineering, Integrated B.S.-M.S.

□ Biochemistry Emphasis in Biotechnology, B.S. □ Computer Science, B.S.

□ Biological Science, Cell and Developmental Biology □ Earth Science, B.A.

Concentration, B.S □ Electrical Engineering, B.S.

□ Biological Science, Ecology and Evolutionary Biology □ Geology, B.S.

Concentration, B.S. □ Health Science, Environmental and Occupational Health

□ Biological Science, Marine Biology Concentration, B.S. and Safety Advising Track, B.S.

□ Biological Science, Molecular Biology and Biotechnology □ Health Science, Global Health Advising Track, B.S

Concentration, B.S. □ Health Science, Health Promotion and Disease Prevention

□ Biological Science, Plant Biology Concentration, B.S. Advising Track, B.S.

□ Chemistry Emphasis in Environmental Chemistry, B.A. □ Mathematics, Actuarial Science Concentration, B.A.

□ Chemistry Emphasis in Environmental Chemistry, B.S. □ Mathematics, Applied Mathematics Concentration, B.A.

□ Chemistry, B.A. □ Mathematics, Probability and Statistics Concentration, B.A.

□ Chemistry, B.S. □ Mathematics, Pure Mathematics Concentration, B.A.

□ Civil Engineering, B.S. □ Mathematics, Teaching Mathematics Concentration, BA

□ Civil Engineering, Civil Engineering with Architectural □ Mechanical Engineering, B.S.

Engineering Emphasis, B.S □ Physics, B.S.

□ Computer Engineering, B.S. □ Physics Business Emphasis, B.S.

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Have you participated in any Citrus College Research Program? □ Yes □ No

Please check all that apply: □ Summer Research Experience

□ Bridge to the Geosciences

□ Rocket Owls □ Galactic Owls □ Ro Squared

□ Other ____________________________

Background Information

Gender: □ Female □ Male □ Transgender

Check any that are applicable: □ Black/African-American □ Asian/Asian-American □ Hispanic/Latino

□ Pacific-Islander □ Native American □ White

□ Other:

Are you currently working? □ Yes □ No If yes, where?

Approximate number of hours per week?

Marital Status: □ Single □ Married □ Divorced □ Widowed

Do you have children? □ Yes (how many) □ No

Do you live with your parents? □ Yes □ No How many people live in your household?

Are you a Veteran of the Armed Services? □ Yes □ No If yes, what branch?

What was the first language you learned? Language spoken most at home now

Do you have any special needs? □ Yes □ No If yes, please explain:

Please indicate the last grade each parent/guardian completed in school and check any diplomas or degrees earned.

Elementary High School Diploma College Degree

Mother 1 2 3 4 5 6 7 8 9 10 11 12 [ ] yes [ ] no 1 2 3 4 [ ] AA/AS [ ] BA/BS

Father 1 2 3 4 5 6 7 8 9 10 11 12 [ ] yes [ ] no 1 2 3 4 [ ] AA/AS [ ] BA/BS

Legal Guardian 1 2 3 4 5 6 7 8 9 10 11 12 [ ] yes [ ] no 1 2 3 4 [ ] AA/AS [ ] BA/BS

Do you have siblings in college? □ Yes (how many?) □ N o

Have any of your siblings completed college? □ Yes (how many?) □ No

If you are currently receiving financial aid, please check all that apply.

□ Board of Governor’s Fee Waiver (BOG) □ Cal Grant □ Pell Grant □ Federal Work Study □ Cal Works □ Not eligible for aid

□ Citrus Scholarship □ Outside Scholarship