NEST Robert Noyce Program Application Form

PERSONAL INFORMATION
Date of Birth_______________
Name ____________________________________________________________________________________
Last

First

Middle

Maiden

Mailing address ____________________________________________________________________________

Number

Street

City

State

Zip

SSN & EMPL ID __________________________________

Telephone (

E-mail __________________________________

INTERNSHIP OR SUMMER PROGRAM

Term applying for (Spring, Summer, Fall) ____________
Check one Summer Program q

Noyce Intern q

EDUCATION
NAME OF COLLEGES ATTENDED

GPA

MAJOR & DEGREE

Are you a United States Citizen or a Green Card holder?

CREDITS
COMPLETED

q Yes

q No

If the answer to the previous question is No, what is your immigration status? _____________________

Signature of applicant: ______________________

Date___________

Application materials include: application form, resume, one recommendation letter, proof of
Citizenship or Green Card status and all unofficial transcripts. Please submit all application
materials to Ms. Lusine Gasparyan at cuny889@gmail.com.
If you have any questions, please contact: Dr. Fangyang Shen at fshen@citytech.cuny.edu
Dr. Andrew Douglas at adouglas@citytech.cuny.edu

STATUS
(Full
time/Part
time)