Application for 2007-2008 Academic Year EDUCATIONAL OPPORTUNITY

DEPARTMENT
MTU MICHIGAN COLLEGE/UNIVERSITY MICHIGAN TECHNOLOGICAL UNIVERSITY
1400 TOWNSEND DRIVE
PARTNERSHIP PROGRAM
HOUGHTON, MI 49931-1295
c/o MADELINE MERCADO VOELKER
Program Date: May 12 – June 27, 2008 Hispanic/Latino Outreach Coordinator

MICUP is funded by the State of Michigan’s King-Chávez-Parks DEADLINE: FEBRUARY 29, 2008
Initiative. Supporting a partnership of Michigan Technological
University, Delta College, Grand Rapids Community College,
Ojibwa Community College and Wayne County Community
College

Please use black ink and print or type all information.

Personal Information
________________________________________________________________________________________
Last Name First Name Middle Initial

/ / M F
_____________________________________________________________________________________________________________________________________________________________________________________________________

Social Security Number Date of Birth Gender

Present Address:
________________________________________________________________________________________
Street Apt.

________________________________________________________________________________________
City State Zip

________________________________________________________________________________________
Phone E-Mail

Race/Ethnicity (Optional – select one or more):

‡ Hispanic/Hispanic American ‡ American Indian/Alaska Native ‡ Asian/Asian
American ‡ Native Hawaiian or Other Pacific Islander ‡ African American/Non-
Hispanic ‡ White/Non-Hispanic

Citizenship:
US Citizen ‡ Yes ‡No ‡ Permanent Resident ‡ Non-Resident Alien
If you are not a US citizen, are you a permanent resident of the US? ‡ Yes ‡ No
If yes, give alien registration number _____________ Date of issue ______________

Statement of Intent:
Write a statement (200 words or more) describing why you would like to participate in the
MICUP Program. What would you like to gain from this experience and how will it help your
career goals?

Academic Information:
College currently attending: ______________________________________________
Have you completed your first year of college courses? ‡ yes ‡ no
Major:________________________________ Minor: _______________________
Cum. GPA___________ Dept. GPA __________
Expected graduation date (mo./year): _____________
Have you had any previous undergraduate research experience? ‡ yes ‡ no over
Faculty or Staff Recommendation
ƒ How long and in what capacity have you known the applicant?_______________
_________________________________________________________________________________

ƒ Please rate the applicant in comparison with others whom you have known at
similar stages in their careers.

Exceptional Very Good Good

Knowledge in chosen
field
Motivation and
perseverance toward
goals
Ability to work
independently
Ability to express
thoughts in speech
and writing

Name (please print) _________________________Signature: _________________

Department:____________________________ Date: ______________________

Applicant
I understand that a Power Point or Poster Presentation will be presented as a requisite of
the MICUP Program. Educational Opportunity may also arrange for pictures and news
articles about my selection and participation in the MTU Undergraduate Research
Program, if requested by the funding agent. Academic achievement, retention and
graduation rates, etc. may be used in aggregate form to evaluate the program.
Information on individual research students will be maintained confidentially.
Attendance to class and internship is mandatory. If I fail my class, I authorize that my
last stipend check be withheld.

X _________________ ______________________
Signature of applicant Date

Checklist:
Completed student section of application Statement of Intent
Faculty or Staff signature and recommendation Applicant's signature
Enclosed transcript

Return To: Madeline Mercado Voelker Phone: (906) 487-2920

MICUP Program Director Fax: (906) 487-3101
or emails: mmercado@mtu.edu
Lori Muhlig muhlig@mtu.edu
MICUP Program Associate Director
Michigan Technological University
Educational Opportunity, 1400 Towsend Drive, Houghton, MI 49931

DEADLINE: February 29, 2008

Michigan Technological University is an equal opportunity educational institution/equal opportunity employer.