MIDWEST ALLIANCE IN SCIENCE, TECHNOLOGY, ENGINEERING AND MATHEMATICS APPLICATION FOR MIDWEST INTERNSHIPS/EXTERNSHIPS NAME: DATE: MAILING ADDRESS: PHONE NUMBER: Required steps: 1. Go to http://www.stemmidwest.org to register. [Applications will not be considered unless applicant is registered.] 2. Review specific criteria and requirements for the program for which you are applying. 3. Verify that you have reviewed the application evaluation criteria and requirements (below). 4. Complete the sections required (below) as part of the application package and mail to the MIDWEST offices (below). ~~~~~~~ ___ Yes, I have completed the MIDWEST registration form and have reviewed the evaluation criteria and requirements. ~~~~~~~ Please indicate the semester for which you are applying. ___ Summer 2006 ___ Fall 2006 ___ Spring 2007 Please indicate the type of program for which you are applying. ___ High School Internship at a College/University ___ College/University Internship at my own College/University ___ College/University Internship at another (not my own) College/University ___ College/University Externship in Industry Setting or Government Agency If you have already identified a laboratory or industry/government agency in which you would like an internship or externship, please indicate it below. ___ College/University Lab ___ Industry/Government agency (Please specify name of lab or agency below, with address, city and state) _________________________________________________ _________________________________________________ _________________________________________________ Name of Professor/Scientist/Researcher ________________________________ SCHOOL/COLLEGE/UNIVERSITY IN WHICH YOU ARE CURRENTLY ENROLLED: School Name_________________________________ Address_____________________________________ _____________________________________ _____________________________________ CURRENT LEVEL OF EDUCATION: (e.g., High School Senior; Year 2 in Technical College; Junior at 4-year University, Doctoral Candidate, etc.) ANTICIPATED GRADUATION DATE: CURRENT MAJOR/AREA OF STUDY (College/University level students only): CURRENT CUMULATIVE GRADE POINT AVERAGE (GPA): ACCOMMODATIONS YOU MIGHT YOU NEED TO COMPLETE YOUR WORK: STATEMENT OF INTEREST: Attach a page to this application that includes a brief statement about why you are interested in an internship or externship and how participation will help you reach your career goals. ~~~~~~~ --Include two letters of recommendation with your application or list the names of those individuals who will be sending letters of recommendation. Your application will not be complete until recommendations have been submitted. --Include a resume describing your education, experiences and interests. --Include an unofficial transcript from your current school, college or university. Applications are accepted on an ongoing basis. Applications will be reviewed within 3-4 weeks of receipt of a full and complete application packet. The MIDWEST grant application packet may be submitted via postal mail or FAX to: Amy Fruchtman, MIDWEST Project Manager University of Wisconsin-Madison 338 Goodnight Hall 1975 Willow Drive Madison, WI 53706 FAX #: (608) 262-6466 Please contact MIDWEST at (608) 262-6467 or Toll Free at (866) 857-4358 if you have questions. REQUEST FOR GRANT MONEY FOR INTERNSHIP/EXTERNSHIP SUPPORT Complete this section only if, in addition to requesting an internship/externship placement, you would also like to apply for grant money support. NAME: AMOUNT OF GRANT MONEY REQUESTED: STATEMENT OF WORK PLAN 1. Describe the grant purpose/how the grant money will be used to support your internship/externship experience. 2. Describe the specific expected outcomes. 3. Describe how the outcomes will be evaluated. BUDGET Itemize proposed costs. OTHER GRANT SOURCES (if applicable) Describe any funding sources/grant money you already have or anticipate receiving to support this internship/externship; include the names of those sources and the amount(s) of grant money available. APPLICATION FOR MIDWEST INTERNSHIPS/EXTERNSHIPS PARENT/GUARDIAN PERMISSION FORM For Applicants Under the Age of 18 Years I give permission for my son/daughter to participate in the MIDWEST activities for which he/she is applying. Printed Name of Parent/Guardian: __________________________________ Signature of Parent/Guardian: _____________________________________ Email Address: _______________________________ Phone Number: ______________________________ Mailing address: _______________________________________ _______________________________________ _______________________________________ Please contact MIDWEST at (608) 262-6467 or Toll Free at (866) 857-4358 if you have questions.