Research and Education in Green Materials

UC TOXIC SUBSTANCES RESEARCH AND TEACHING PROGRAM

APPLICATION FOR TRAINEESHIP Circle Campus: BERKELEY ž DAVIS ž IRVINE ž LOS ANGELES ž MERCED ž RIVERSIDE ž SAN DIEGO ž SAN FRANCISCO ž SANTA BARBARA ž SANTA CRUZ
Title of Research Project
Period of Support Requested (max. 12 months)	Start Date			End Date
Name (Last, First, Middle Initial)			Date of Application
Home Address (Street/P.O. Box, City, ST, Zip)
Home Telephone	Work/Lab Telephone		Work/Lab Fax
E-mail Address		Your Dept.
University of California ID# (xxx-xxx-xxx)
Gender Female Male	Birthdate (mm/dd/yy)		Ethnicity (optional)
Citizenship: U.S. Citizen or U.S. Noncitizen National Permanent Resident of U.S. – Alien Registration Number Visa Type of Visa Expiration Date If not a citizen or US permanent resident: Country of Citizenship: Place of Birth – City/Province/Region Passport Number: Expiration Date:

Faculty Mentor:		Mentor’s Dept.
Mentor’s Campus Address with Mail Code ( )		Mentor’s Telephone
Mentor’s E-mail Address		Mentor’s Fax
Mentor’s Complete Mailing Address
Your Dept. Financial Personnel Contact (full name)	Dept. Telephone	Dept. Fax
Are you presently covered by medical insurance? Yes No If yes, please name carrier:

Education – After High School (Indicate all academic and professional education. For foreign degrees, give U.S. equivalent)
Name of Institution, Department and Location	Attendance Mo/Yr	Degree(s) Received		Major Field Minor Field
	From To	Degree Grade Pt. Avg.	Mo/Yr
Baccalaureate Degree
Postgraduate
Foreign Applicants – List Official TOEFL score (if applicable):
Are you currently supported by a training grant or other fellowship? If yes, Award Name & Agency: Award Period:
Have you received a TSR&TP training grant support in the past? If yes, Grant Name: Award Period:
I agree to participate in the Lead Campus Program activities as described in the Award Description. Signature ________________________________________ Date _________________________