NASA Earth System Science Fellowship Program

Student Information

Salutation(Mr/Ms): First Name (given name): Surname (family name): Birth Date: (mm/dd/yy)date format required e.g. 01/21/96 Birthplace: Permanent Address: Home Phone: Citizenship: Expected Degree Completion Date: (mm/dd/yy)date format required e.g. 01/21/96 Campus Address: Department: Mail Code: University: Street Address: City: State: ZIP: Campus Phone: Fax: E-Mail: Undergraduate GPA: Discipline: Graduate GPA: Discipline:

Proposal Information

(Must select 1)
Degree Program:  M. Sc.  Ph.D.


X Applicable Global Change Category:
(Must select 1)

  Climate and Hydrologic Systems

  Data and Information Systems

  Solid Earth Processes

  Human Interactions

  Ecological Systems and Dynamics

  Biogeochemical Dynamics

  Solar Influences


	
   Proposal Title (not to exceed 250 characters):

Faculty Advisor Information 

   Salutation(Mr/Ms/Dr): 
First Name (given name): 
  Surname (family name): 
         Campus Address: 
             Department: 
              Mail Code: 
             University: 
         Street Address: 
			 
                   City: 
                  State: 
                    ZIP: 
           Campus Phone: 	Fax:
                 E-Mail: 
              Signature:    
                   Date:  (mm/dd/yy)date format required e.g. 01/21/96

Official Responsible for Committing Institution 

   Salutation(Mr/Ms/Dr): 
First Name (given name): 
  Surname (family name): 
                  Title: 
             University: 
         Street Address: 
			 
                   City: 
                  State: 
                    ZIP: 
           Campus Phone: 

	Drug Free Workplace Certification (attach)	   


	Debarment and Suspension Certification (attach)	   


              Signature: 
                   Date:  (mm/dd/yy)date format required e.g. 01/21/96

Submission Checklist

(incomplete files will not be considered for award)



 X  Application Form

 X  Research Proposal (5-6 pages)

 X  Abstract

 X  Transcripts

 X  Recommendation Letter

 X  Schedule

 X  Certifications

 X  Optional Information Form
   (Not Required for Consideration)




I certify that I am or will be a full-time graduate student enrolled
at an accredited U.S. university during the period covered in the
attached proposal.


      Signature:  
           Date:  (mm/dd/yy)date format required e.g. 01/21/96

Optional Information Form 

In order to determine the degree of which members of each
ethnic/racial/disability group are reached by this announcement, NASA
requests that the student check the appropriate block(s).  Submission
of this information is optional and will not affect your application.

(Must select 1)
Do not wish to disclose.
AMERICAN INDIAN
ASIAN *
BLACK
HISPANIC
PACIFIC ISLANDER * *
WHITE

Individuals with disabilities:
(Must select 1)
Do not wish to disclose.
No
Yes * * *

(Must select 1)
Do not wish to disclose.
Female
Male 

* This area includes, for example, China, India, Japan, and Korea.


* * This area includes any of the original peoples of Hawaii; the U.S. Pacific Territories of Guam, 
American Samoa, and the Northern Marianas; the U.S. Trust Territory of Palau; the Islands of 
Micronesia and Melanesia; and the Philippines.


* * * A disability that limits a major life activity.
After pressing the "submit input" button, you will then be presented with a screen containing the information you entered. Please print that information. Submit the printed copy with original signatures of the Student, Faculty Advisor and Official Responsible for Committing Institutions, with seven (7) copies of your proposal.