Mailing Address:
Street:   City:   State:   ZIP:

Phone (include area code):
Home:   Cell:

Are you a U.S. citizen?  yes  no

If not, are you a permanent resident?  yes  no

In which college are your registered?  

Number of college list credits completed:

What was your GPA at the end of last semester?

Have you complete at least a year of college physics?   yes  no

Have you completed other college physics, chemistry, biology or geology coursework?  yes  no

If yes, indicate college, title and number for the course(s)
(e.g., York, Chemistry I, Chem 101)

Have you had any experience in an independent studies course?  yes  no

If yes, indicate college and number for the course(s)
(e.g., York, Physics 495)

Please describe in 500 words why you want to be involved in this internship program.