RESEARCH EXPERIENCE for Teachers PROGRAM

Eligibility: Internships are offered on a competitive basis to United States citizens or U. S. Legal Permanent Residents who are teaching science full time.

APPLICATION, Summer 2008

Research Experiences for Teachers (RET) Program

Center on Polymer Interfaces and Macromolecular Assemblies (CPIMA)

A Stanford University, UC Davis, UC Berkeley IBM Almaden Partnership

Section I.
1. Full Name (first, last)
2. Social Security Number
3. I am a	US Citizen US Legal Permanent Resident Other (may be ineligible)
4. Email Address
5. Home Mailing Address
5. City
5. State
5. Zip Code
5. Phone Number
6. Alternate Email Address
Questions 7, 8, and 9 are Optional.	(The following information is used by the NSF for statistical purposes only)
7. I am	Decline to specify Male Female
8. Ethnicity
9. Physical Challenges or Special Needs, etc.
Section II.
10. School Name
11. School Mailing Address
5. City
5. State
5. Zip Code
5. Phone Number
12. Principal's Name
13. Total number of years teaching science at the K-12 level
14. Number of years teaching at current school
15. List courses and grade levels you are currently teaching (indicate if labs are included)
Course name	Grade level	# of classes	Lab included?
			yes no
			yes no
			yes no
			yes no
			yes no
16. What strengths do you bring to teaching?
17. What approaches have you used to stimulate your students' interest in science?
18. What experience do you have in science curriculum development? (At your site, within your district, at the state/national level)
Section III.
19. Undergraduate Institution You Attended
20. Major(s)
21. Degree earned and date of graduation (month and year)
22. Teaching Credential
23. List undergraduate and graduate (college level) science and math courses completed. (if more than 10, list 10 most relevant)
Course name	Date completed	Where taken	Lab included?
			yes no
			yes no
			yes no
			yes no
			yes no
			yes no
			yes no
			yes no
			yes no
			yes no
24. Have you previously worked or volunteered in a research or industrial laboratory? (Indicate dates & places)
Section IV.
25. If offered an RET Fellowship, what area of research would be of interest to you? (If not sure, please write in “not sure at this time”).
26. Location: Please indicate your location preference(s) for an internship with CPIMA.	Stanford University (Stanford,CA)
27. Date: Please indicate your preferred start date.	Monday, June 16th Monday, June 23rd
28. Why would you like to be involved in this program?
29. In what ways could you imagine applying or involving scientific research in a classroom setting? (Be creative about the possibilities)
30. Other pertinent information (i.e.; publications, advisor to students' clubs; Intel Science Talent Search projects)
Section V.
31. References: List two references who can provide information about your teaching skills and your interest in science.
A. Name & Title
A. Company/Institution
A. Address
A. City
A. State
A. Zip Code
A. Phone
A. Email
B. Name & Title
B. Company/Institution
B. Address
A. City
A. State
A. Zip Code
B. Phone
B. Email
32. I hereby certify that all information provided on this application is true and complete to the best of my knowledge. If accepted, I understand that providing false information is grounds for dismissal from the CPIMA RET program. (The following is your electronic "signature" and is considered binding.)
Initials
Date
Full Name
33. CPIMA has my permission to copy all parts of my application (application, letters of reference, transcripts) for internal distribution to members affiliated with CPIMA during the RET selection process.
I agree	I do not agree
34. How did you learn about the RET Program?

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