Georgia Space Grant Consortium

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Fellowship/Graduate Assistantship
Application

FOR STUDENTS APPLYING TO GEORGIA TECH ONLY

Part 1

Required fields are indicated by *

Last name * :
First name * :
Address :
City :
State :
Zip :
Email address * :
Phone number * :
Additional Contact phone number :
For statistical information only
Date of Birth :
Gender :	Female Male
Race : Black/African American Latino Native American Pacific Islander White Caucasian Other
Are you a person with disability ?	Yes No
Education level :	Undergraduate Graduate
If graduate level, please name undergraduate institution :
Please list all other sources of financial support including Duration and Amounts :
Source: Duration: Amount: Source: Duration: Amount: Source: Duration: Amount:
How much funding per semester are you requesting ?
When do you need funding and for how many semesters ?
Current GPA (Official transcript required for verification) :
Major and Minor :
Advisor :
Target Degree :
Anticipated graduation date :
Three reference letters are required within one month of submission of your application. At least one reference must be (academic) from a teacher and/or professor (if you are a grad student). All references can be emailed to gsgc@gatech.edu Please submit the following information for your 3 references :
Name: Title: Place of Employment: Name: Title: Place of Employment: Name: Title: Place of Employment:
How did you find out about the Georgia Space Grant Consortium Fellowship Program?
I agree to participate in longitudinal tracking surveys (for NASA and the Georgia Space Grant Consortium); acknowledge the Georgia Space Grant (as appropriate); and agree to inclusion in public information (newsletters, website).
Initials * : Date * :