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{\info{\title Application form}{\author C. Gan}{\operator james defenbaugh}{\creatim\yr2008\mo2\dy25\hr20\min54}{\revtim\yr2008\mo2\dy25\hr20\min54}{\printim\yr2007\mo3\dy1\hr12\min22}{\version2}{\edmins0}{\nofpages2}{\nofwords1072}{\nofchars6116}
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\b\f36\fs18\uldb\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 Application for the }{\insrsid15017612 2008}{\insrsid5320472  HHMI SUMMER SCIENCE PROGRAM FOR HIGH SCHOOL STUDENTS AT HUMBOLDT STATE
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   Molecular Biology/ Chemistry workshop}{\cf0\insrsid15017612 \tab }{\cf1\insrsid15017612 July 7}{\cf1\insrsid5320472 , }{\cf1\insrsid15017612 2008 \endash  August 1}{\cf1\insrsid5320472 , }{\cf1\insrsid15017612 2008}{\cf0\insrsid5320472 
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April 12}{\insrsid5320472 , }{\insrsid15017612 2008}{\insrsid5320472 \tab \tab \tab Final postmark deadline: }{\insrsid15017612 May 31}{\insrsid5320472 , }{\insrsid15017612 2008}{\insrsid5320472 \tab 
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PLEASE PRINT CLEARLY. }{\insrsid1837763\charrsid5320472 \tab THE BROCHURE AND THIS APPLICATION CAN BE COPIED AS NEEDED.}{\insrsid5320472\charrsid5320472 
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To participate in the }{\fs20\insrsid15017612\charrsid13004360 2008}{\fs20\insrsid5320472\charrsid13004360  program, you must currently be a high school sophomore}{\fs20\insrsid16595804\charrsid13004360  (sophomore in 2007/2008 academic year)}{
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What high school do you currently attend? ____________________________When will you graduate? _____________
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: __________________________________________________________________________________________________
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0008000000fa0206000100000000000000040000002d0100000500000014021100040005000000130211007b00050000001402100004000500000013020200040005000000140211002b0005000000130203002b00050000001402100040000500000013020200400005000000140210007b0005000000130202007b000500
00001402100010000500000013020b00100005000000140210001d000500000013020b001d00050000001402100036000500000013020b00360005000000140210004e000500000013020b004e0005000000140210005c000500000013020b005c0005000000140210006b000500000013020b006b000a00000026060f000a
00ffffffff010000000000040000002701ffff030000000000}}}{\fs20\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\tx1260\tx2160\tx2880\tx5040\tx7920\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs14\insrsid5320472 \tab         Month\tab            Day\tab                Year
\par }\pard \ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\b\fs20\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 {\b\fs20\insrsid5320472 Current mailing address:}{\fs20\insrsid5320472  
\par }\pard \ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs32\insrsid5320472 ____________________________________________________________________________
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx8540\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs18\insrsid5320472 \tab Street number\tab Street name\tab Apartment
\par }\pard \ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs20\insrsid5320472 ____________________________________________________________________               }{\pard\plain 
\ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 \f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5851317 {\pict\wmetafile8\picw4762\pich705\picwgoal2700\pichgoal400 
010009000003600000000100080000000000050000000b0200000000050000000c02140087000500000004010d000000050000002e01180000000500000002010100000005000000090200000000050000000102ffffff00030000001e0008000000fa0206000100000000000000040000002d010000050000001402100006
000500000013021000860005000000140210000600050000001302020006000500000014020f00860005000000130201008600040000002701ffff030000000000}}}{\fs20\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx7920\tx8747\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs18\insrsid5320472 \tab City \tab State\tab \tab   Zip code}{\fs20\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx5940\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\b\fs20\insrsid5320472 Home telephone}{\fs18\insrsid5320472  }{\pard\plain \ql \li0\ri-1440\widctlpar
\tx1440\tx5040\tx5940\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 \f36\fs18\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5851317 {\pict\wmetafile8\picw4903\pich705\picwgoal2780\pichgoal400 
0100090000036a0000000100080000000000050000000b0200000000050000000c0214008b000500000004010d000000050000002e01180000000500000002010100000005000000090200000000050000000102ffffff00030000001e0008000000fa0206000100000000000000040000002d0100000500000014020f0009
000500000013020f008a000500000014020e000900050000001302030009000500000014020f002e0005000000130204002e000500000014020f008a0005000000130203008a00040000002701ffff030000000000}}}{\fs18\insrsid5320472 \tab \tab }{\b\fs20\insrsid5320472 Cell phone}{
\fs18\insrsid5320472  }{\pard\plain \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx5940\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 \f36\fs18\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5851317 {\pict\wmetafile8\picw4621\pich705
\picwgoal2620\pichgoal400 
0100090000036a0000000100080000000000050000000b0200000000050000000c02140083000500000004010d000000050000002e01180000000500000002010100000005000000090200000000050000000102ffffff00030000001e0008000000fa0206000100000000000000040000002d0100000500000014020f0009
000500000013020f0082000500000014020f000800050000001302040008000500000014020f002e0005000000130204002e000500000014020f00820005000000130203008200040000002701ffff030000000000}}}{\fs18\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx2880\tx7200\tx8640\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs14\insrsid5320472 \tab            Area code\tab Number\tab Area code\tab Number
\par }\pard \ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 {\b\fs20\insrsid5320472 
\par }\pard\plain \s1\ql \li0\ri-1440\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 
Email address (please print clearly): ____________________________________________________ 
\par }\pard\plain \ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 
\par }{\b\fs20\insrsid5320472 Summer }{\b\fs20\insrsid15017612 2008}{\b\fs20\insrsid5320472  address and phone number (if different from current address and phone number):}{\fs20\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs32\insrsid5320472 ____________________________________________________________________________
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx8540\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs18\insrsid5320472 \tab Street number\tab Street name\tab Apartment
\par }\pard \ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs20\insrsid5320472 ____________________________________________________________________}{\pard\plain 
\ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 \f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5851317 {\pict\wmetafile8\picw4762\pich705\picwgoal2700\pichgoal400 
010009000003600000000100080000000000050000000b0200000000050000000c02140087000500000004010d000000050000002e01180000000500000002010100000005000000090200000000050000000102ffffff00030000001e0008000000fa0206000100000000000000040000002d010000050000001402100006
000500000013021000860005000000140210000600050000001302020006000500000014020f00860005000000130201008600040000002701ffff030000000000}}}{\fs20\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs18\insrsid5320472 \tab City \tab State\tab Zip code
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx5940\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\b\fs20\insrsid5320472 Home telephone}{\fs18\insrsid5320472  }{\pard\plain \ql \li0\ri-1440\widctlpar
\tx1440\tx5040\tx5940\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 \f36\fs18\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5851317 {\pict\wmetafile8\picw4903\pich705\picwgoal2780\pichgoal400 
0100090000036a0000000100080000000000050000000b0200000000050000000c0214008b000500000004010d000000050000002e01180000000500000002010100000005000000090200000000050000000102ffffff00030000001e0008000000fa0206000100000000000000040000002d0100000500000014020f0009
000500000013020f008a000500000014020e000900050000001302030009000500000014020f002e0005000000130204002e000500000014020f008a0005000000130203008a00040000002701ffff030000000000}}}{\fs18\insrsid5320472 \tab \tab }{\b\fs20\insrsid5320472 Cell phone}{
\fs18\insrsid5320472  }{\pard\plain \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx5940\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 \f36\fs18\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5851317 {\pict\wmetafile8\picw4621\pich705
\picwgoal2620\pichgoal400 
0100090000036a0000000100080000000000050000000b0200000000050000000c02140083000500000004010d000000050000002e01180000000500000002010100000005000000090200000000050000000102ffffff00030000001e0008000000fa0206000100000000000000040000002d0100000500000014020f0009
000500000013020f0082000500000014020f000800050000001302040008000500000014020f002e0005000000130204002e000500000014020f00820005000000130203008200040000002701ffff030000000000}}}{\fs18\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx2880\tx7200\tx8640\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs14\insrsid5320472 \tab            Area code\tab Number\tab Area code\tab Number
\par }\pard\plain \s1\ql \li0\ri-1440\keepn\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 
\par }\pard\plain \ql \li0\ri-1440\widctlpar\tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\b\fs20\insrsid5320472 
Who recommended that you apply for this program? }{\fs20\insrsid5320472 (provide phone # if possible)}{\b\fs20\insrsid5320472  ____________________________________
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 {\b\fs20\insrsid5320472 
\par }\pard\plain \s1\ql \li0\ri-1440\keepn\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 If your summer }{\insrsid15017612 
2008}{\insrsid5320472  address is in outlying areas such as the Klamath-Trinity region, the Fortuna area, or 
\par southern Humboldt, please indicate any hardships or other concerns you will have in getting to class.  
\par }\pard\plain \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\fs32\insrsid5320472 
__________________________________________________________________________
\par __________________________________________________________________________
\par __________________________________________________________________________
\par }\pard\plain \s27\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 
\par If you live in the Klamath-Trinity region, do you feel you will use the HTA (Humboldt Transit Authority) bus? }{\b0\insrsid5320472 (departs Willow Creek at 9:40am, departs Arcata at 5:25pm)}{\insrsid5320472   or do you prefer to make carpool arrangements?

\par }\pard\plain \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\fs32\insrsid5320472 
______________________________________________________________________
\par ______________________________________________________________________
\par }\pard\plain \s1\ql \li0\ri-1440\keepn\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 
\par For all students accepted to the program, to facilitate potential carpool arrangements, can we provide other 
\par students with your phone number and/or email address to facilitate those arrangements?  Phone #  email address 
\par }{\fs18\insrsid5320472 \tab \tab }{\insrsid5320472 (over)}{\fs18\insrsid5320472 \tab }{\insrsid5320472 (circle one, both or neither)
\par }\pard\plain \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\fs32\insrsid5320472 \tab \tab }{\insrsid5320472 \tab \tab \tab \tab \tab 
      
\par }\pard\plain \s3\ql \li2880\ri-1440\keepn\widctlpar\tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\outlinelevel2\adjustright\rin-1440\lin2880\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 \tab \tab 
Name __________________________________________
\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\b\fs20\insrsid5320472 Part II
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 {\b\fs10\insrsid5320472 
\par }\pard \ql \li0\ri0\nowidctlpar\faauto\rin0\lin0\itap0 {\b\fs20\cf1\insrsid5320472 List the main sources of income for your household (include government aid: AFDC, etc.)
\par }\pard\plain \s8\ql \li0\ri0\keepn\nowidctlpar\faauto\outlinelevel7\rin0\lin0\itap0 \i\f36\fs20\ul\cf1\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\b\uldb\insrsid5320472 Name}{\uldb\insrsid5320472 \tab \tab \tab  }{\b\uldb\insrsid5320472 Relation}{
\uldb\insrsid5320472 \tab  }{\b\uldb\insrsid5320472 Source}{\uldb\insrsid5320472  \tab \tab \tab \tab }{\b\uldb\insrsid5320472 Occupation}{\uldb\insrsid5320472 \tab  \tab }{\b\uldb\insrsid5320472 Yearly Income}{\uldb\insrsid5320472 
\par }\pard\plain \ql \li0\ri0\nowidctlpar\faauto\rin0\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\i\fs20\cf1\insrsid5320472 Example. }{\fs20\cf1\insrsid5320472 (Last, First) \tab Mother \tab \tab 
(Name of workplace or govt. agency) \tab (Job/profession) \tab \tab $27,000.00
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs20\insrsid5320472 1. }{\fs32\insrsid5320472 __________________________________________________________________________
\par }{\fs20\insrsid5320472 2. }{\fs32\insrsid5320472 __________________________________________________________________________
\par }{\fs20\insrsid5320472 3. }{\fs32\insrsid5320472 __________________________________________________________________________
\par }\pard\plain \s1\ql \li0\ri-1440\keepn\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 
\par }\pard\plain \ql \li0\ri0\nowidctlpar\faauto\rin0\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\b\fs20\insrsid5320472 Total household income ___________________________________ }{\fs20\insrsid5320472 
(supporting documents may be requested)}{\b\fs20\insrsid5320472 
\par }\pard\plain \s1\ql \li0\ri-1440\keepn\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 
\par }\pard\plain \s6\ql \li0\ri0\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel5\adjustright\rin0\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 Father\rquote s level of education (check): \tab }{
\insrsid5320472 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f10\fs20}}}{\insrsid5320472  not high school grad.\tab }{\insrsid5320472 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f10\fs20}}}{\insrsid5320472 
 high school grad.\tab }{\insrsid5320472 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f10\fs20}}}{\insrsid5320472  college graduate
\par }\pard\plain \s1\ql \li0\ri-1440\keepn\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\b0\insrsid5320472 
If father college grad.:  Highest degree obtained______________________School_______________________________ 
\par }\pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 
\par }\pard\plain \s6\ql \li0\ri0\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel5\adjustright\rin0\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 Mother\rquote s level of education (check): }{\insrsid5320472 
{\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f10\fs20}}}{\insrsid5320472  not high school grad.\tab }{\insrsid5320472 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f10\fs20}}}{\insrsid5320472  high school grad.\tab }{
\insrsid5320472 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f10\fs20}}}{\insrsid5320472  college graduate
\par }\pard\plain \s1\ql \li0\ri-1440\keepn\widctlpar\tx1440\tx5040\tx7920\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\b0\insrsid5320472 
If mother college grad.:  Highest degree obtained______________________School_______________________________ 
\par }\pard\plain \ql \li0\ri-1440\widctlpar\tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\fs20\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\brdrt\brdrs\brdrw30\brsp20 \tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\rtlgutter\itap0 {\fs16\insrsid5320472 
\par }\pard\plain \s1\ql \li0\ri-1440\keepn\widctlpar\tx1440\tx5040\tx5760\tx6390\tx7740\tx8640\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\insrsid5320472 Part III
\par }\pard\plain \ql \li0\ri-1440\widctlpar\tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\b\fs10\insrsid5320472 
\par }\pard \ql \li0\ri0\nowidctlpar\faauto\rin0\lin0\itap0 {\f213\fs18\cf1\insrsid5320472 Country of Heritage/Nationality__________________Native language _________________ Primary language spoken at home__________
\par }{\f213\fs16\cf1\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx5040\tx7380\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 {\fs20\insrsid5320472 Are you 
a member of one of the ethnic groups listed below? __________ (yes or no)    If yes, please check one or more boxes:
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs20\insrsid5320472 
\par }{\insrsid5320472 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 12}{\fldrslt\f10\fs24}}}{\fs20\insrsid5320472 American Indian or Alaskan native \tab }{\insrsid5320472 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 12}{\fldrslt\f10\fs24}}}{
\fs20\insrsid5320472 African American\tab }{\insrsid5320472 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 12}{\fldrslt\f10\fs24}}}{\insrsid5320472  }{\fs20\insrsid5320472 Latino/Hispanic\tab }{\insrsid5320472 {\field{\*\fldinst SYMBOL 111 \\f "Wingdin
gs" \\s 12}{\fldrslt\f10\fs24}}}{\insrsid5320472  }{\fs20\insrsid5320472 Pacific Islander
\par 
\par If no, please indicate your ethnic background ___________________________________________
\par 
\par }\pard \ql \li0\ri-1440\widctlpar\brdrt\brdrs\brdrw30\brsp20 \tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\rtlgutter\itap0 {\fs16\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 {\b\fs20\insrsid5320472 Part IV}{\fs20\insrsid5320472 
\par }{\b\fs10\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs20\insrsid5320472 If applicable, enter test scores and dates taken, or the date that you will take each test:
\par PLAN\tab _________      _________      _________      _________      _________ \tab Date:  ______________________
\par \tab }{\fs18\insrsid5320472 English                Math                      Reading                Science                }{\fs14\insrsid5320472 COMPOSITE SCORE}{\fs18\insrsid5320472 
\par }{\fs20\insrsid5320472 ACT\tab _________      _________      _________      _________      _________ \tab Date:  ______________________
\par \tab }{\fs18\insrsid5320472 English                Math                      Reading                Science                }{\fs14\insrsid5320472 COMPOSITE SCORE}{\fs18\insrsid5320472 
\par }{\fs20\insrsid5320472 PSAT taken\tab _________      _________      _________     _________            \tab \tab Date:  ______________________
\par after 3-2005:}{\fs18\insrsid5320472 \tab Critical reading   Math\tab          Writing               TOTAL
\par 
\par }{\fs20\insrsid5320472 SAT taken\tab _________      _________      _________     _________            \tab \tab Date:  ______________________
\par after 3-2005:}{\fs18\insrsid5320472 \tab Critical reading   Math\tab          Writing               TOTAL
\par }\pard \ql \li0\ri-1440\widctlpar\brdrb\brdrs\brdrw30\brsp20 \tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\b\fs16\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx3600\tx5760\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0 {\b\fs10\insrsid5320472 
\par }{\b\fs20\insrsid5320472 Part V
\par }{\b\fs10\insrsid5320472 
\par }{\b\fs20\insrsid5320472 Certification}{\fs20\insrsid5320472 : My signature certifies the accuracy and completeness of the information provided. 
\par 
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx4320\tx5760\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs20\insrsid5320472 _______________________________________________________\tab __________________________________
\par }\pard \ql \li0\ri-1440\widctlpar\tx1440\tx4760\tx5760\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\fs20\insrsid5320472 Applicant's Signature\tab \tab Date
\par }{\fs16\insrsid5320472 
\par }\pard \ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 {\f0\fs20\insrsid5320472\charrsid221736 Note:  }{\b\f0\fs20\insrsid5320472\charrsid221736 You must attach a brief personal statement}{
\f0\fs20\insrsid5320472\charrsid221736  (at least 2 paragraphs, no more than one single spaced page) indicating 
\par your goals to this point in your life and why you feel you would benefit from }{\f0\fs20\insrsid3030591 the }{\f0\fs20\insrsid5113672 Molecular Biology/ Chemistry workshop}{\f0\fs20\insrsid221736\charrsid221736 .  }{\f0\fs20\insrsid5320472\charrsid221736 
Please }{\f0\fs20\insrsid221736\charrsid221736 
\par }{\b\f0\fs20\insrsid5320472\charrsid221736 attach a copy of your official high school transcript}{\f0\fs20\insrsid5320472\charrsid221736  to this application. (Ask for this in the high school office.  Allow }{\f0\fs20\insrsid1837763\charrsid221736 
at least }{\f0\fs20\insrsid5320472\charrsid221736 a couple }{\f0\fs20\insrsid221736\charrsid221736 
\par }{\f0\fs20\insrsid5320472\charrsid221736 of days for it to be prepared.)  }{\b\f0\fs20\insrsid5320472\charrsid221736 Send completed application to: Dr. Jacob Varkey, Biology Department, }{\b\f0\fs20\insrsid221736\charrsid221736 HSU}{
\b\f0\fs20\insrsid5320472\charrsid221736 , Arcata, CA  95521.}{\b\f0\fs20\insrsid221736\charrsid221736 
\par }{\b\f0\fs16\insrsid221736\charrsid221736 
\par }\pard\plain \s1\ql \li0\ri-1440\keepn\widctlpar\aspalpha\aspnum\faauto\outlinelevel0\adjustright\rin-1440\lin0\itap0\pararsid221736 \b\f36\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\f0\insrsid221736\charrsid221736 
Limited seats available-apply early- priority postmark deadline of }{\f0\insrsid3030591 Saturday}{\f0\insrsid221736\charrsid221736 , }{\f0\insrsid15017612 April 12}{\f0\insrsid221736\charrsid221736 , }{\f0\insrsid15017612 2008}{
\f0\insrsid221736\charrsid221736  }{\b0\f0\insrsid221736\charrsid221736 (we will begin accepting qualified 
\par students into the program shortly after this deadline).}{\f0\insrsid221736\charrsid221736   }{\b0\f0\insrsid221736\charrsid221736 The }{\f0\insrsid221736\charrsid221736 final postmark deadline for completed applications is }{\f0\insrsid3030591 Sat}{
\f0\insrsid221736\charrsid221736 ., }{\f0\insrsid15017612 May 31}{\f0\insrsid221736\charrsid221736 .}{\b0\f0\insrsid221736\charrsid221736   
\par }\pard\plain \ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0 \f36\fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\b\f0\fs16\insrsid221736\charrsid221736 
\par }\pard \ql \li0\ri0\nowidctlpar\faauto\rin0\lin0\itap0\pararsid221736 {\f0\fs20\insrsid221736\charrsid221736 There is no charge for these workshops.}{\b\f0\fs20\insrsid221736\charrsid221736  }{\b\f0\fs20\insrsid15017612 S}{
\b\f0\fs20\insrsid221736\charrsid221736 ophomores selected for }{\b\f0\fs20\insrsid5113672 Molecular Biology/ Chemistry workshop}{\b\f0\fs20\insrsid15017612  }{\b\f0\fs20\insrsid221736\charrsid221736 will\~
receive a $250 stipend upon completion of the program.\~}{\f0\fs20\insrsid221736\charrsid221736  }{\b\f0\fs20\insrsid221736\charrsid221736 Some additional funding is available to offset travel costs\~from outlying areas.}{
\f0\fs20\insrsid221736\charrsid221736  Only students who complete the }{\f0\fs20\insrsid5113672 Molecular Biology/ Chemistry workshop}{\f0\fs20\insrsid221736\charrsid221736  will be eligible to apply for the Research Program.\~ }{
\b\f0\fs20\insrsid221736\charrsid221736 Each student who completes the Research Program will receive a $1000 college scholarship.}{\b\f0\fs20\insrsid15017612 
\par }\pard \ql \li0\ri-1440\widctlpar\aspalpha\aspnum\faauto\adjustright\rin-1440\lin0\itap0\pararsid221736 {\f0\fs20\insrsid221736\charrsid221736 Please contact Dr. Varkey at (707) 826-4164 or }{\field\flddirty{\*\fldinst {
\f0\fs20\insrsid221736\charrsid221736  HYPERLINK "mailto:jpv1@humboldt.edu" }{\f0\insrsid1796919 {\*\datafield 
00d0c9ea79f9bace118c8200aa004ba90b0200000003000000e0c9ea79f9bace118c8200aa004ba90b320000006d00610069006c0074006f003a006a007000760031004000680075006d0062006f006c00640074002e006500640075000000000083}}}{\fldrslt {
\cs34\f0\fs20\ul\insrsid221736\charrsid221736 jpv1@humboldt.edu}}}{\f0\fs20\insrsid221736\charrsid221736  if you have any questions or need more information.}{\b\f0\fs20\insrsid221736\charrsid221736 
\par }}