General Information

First Name:      Middle Initial:      Last: 

Date of Birth: 

Home Address: 

City:       State:       Zip: 

Email Address:      

Home Phone (e.g. 012-345-6789):  

College Address (upcoming year): 

City:       State:       Zip: 

Currently College Enrolled: 

Academic Standing (Fresh., Soph., etc.): 

Are you currently enrolled in an engineering curriculum?:  none Yes No

Have you declared a major?:  Yes none No      If so, is it Chemical Engineering?:  none Yes No

Academic Achievements

Current Overall Grade Point Average (e.g. 3.8/4.0):  

List your registered courses for next semester (Course 1, Course 2, etc.):

Honors, other scholarships or awards received, research or other internships, and any other details on your progress, projects, and / or plans that you like us to know.

When you are finished and have reviewed your entries, press Submit.  By pressing the Submit button, you are claiming that all information in this application is complete and correct to the best of your knowledge.