CALIFORNIA STATE UNIVERSITY, LOS ANGELES

5151 STATE UNIVERSITY DRIVE
DEPARTMENT OF BIOLOGICAL SCIENCES
CSULA-LSAMP
ASCB – Room 323A
323-343-2095 or lsamp@calstatela.edu

Dear New Applicant to LSAMP:
The major objectives of the Louis Stokes Alliance for Minority Participation [LSAMP] program are to increase
the numbers of students who graduate in a timely fashion in a SEM (science, engineering or mathematics)
discipline and to increase the numbers of students who go on to pursue research careers by pursuing SEM
graduate studies.
Attached with this letter is the NEW LSAMP Student application form for students who have never previously
filed a new application with LSAMP. You have until September 23, 2013, to submit the TYPED and
COMPLETED materials on the attached application form including the required signatures (do NOT leave any
questions blank and follow all instructions). Here are some important things to be aware of:





One of the staff will take a digital head shot at the time you submit your application (your application is
considered incomplete without this photo; photos will be used for recognizing your achievements and if
you are graduating this year to recognize that achievement)
If you fail to submit this new application form correctly and completely by September 23, 2013 (which
includes the digital photo), your application will be rejected for Fall Quarter 2013.
Applications that are not typed will not be accepted and this includes following all instructions
(particularly for the academic plan – use the proper abbreviations as instructed on the top of the
academic plan; obtain the appropriate signatures on the plan as indicated in both the checklist and top
of the academic plan; please note: that if you are a Biology or Microbiology major, Dr. Jefferson can
approve your plan if it is done correctly according to prior advisement; if you are in the MEP program,
MEP staff may approve your plan if it is done correctly and you have met with an academic advisor).
Please make sure that you speak to an academic advisor BEFORE you complete your plan. Most SEM
courses have prerequisites and courses must be taken in specific order to successfully complete the
course on your first attempt.
During the academic year, you will receive the LSAMP REPORT FORM. You must complete and
submit it by the indicated deadline.
We will examine your submitted LSAMP REPORT FORM, your level of participation in research or
other LSAMP activities, your academic progress and your overall academic performance to determine
whether or not you are eligible for other specific program incentives including priority registration.
As we receive information, we will continue to send you emails about various opportunities in the LA
area, throughout California, the USA, as well as various global opportunities.
We have many opportunities to provide funding to students to attend professional conferences, visit
graduate schools, GRE preparation, and to learn about summer internships (note that deadlines for
summer internships are often in winter or early spring quarters.)
Visit the LSAMP website for more information: https://lsamp.calstatela.edu

If you have any questions about your application, contact us by email (lsamp@calstatela.edu) or by phone
(323/343-2095). If you call us, please speak slowly and clearly leaving a message with your name and phone
number for us to call you back. IF YOUR ADDRESS, PHONE NUMBER, E-MAIL ADDRESS, OR NAME, ETC.,
CHANGES, PLEASE INFORM THE LSAMP OFFICE AS SOON AS POSSIBLE.

CSU-LSAMP is supported by the National Science Foundation under Grant # HRD-1302873 and the CSU Office of the Chancellor.

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CSU, Los Angeles
Louis Stokes Alliance for Minority Participation Program

LSAMP NEW APPLICANT INFORMATION
DEADLINE TO APPLY FOR 2013-2014 = September 23, 2013 (NEW Participants)
You will only have to complete this application once while you are a student at CSULA so do it very carefully.
Incomplete applications will not be accepted. Use check list below and make sure you answer ALL questions!
You may bring all of these completed items to the LSAMP office (ASCB - Room 323A). Or if you prefer, you
may mail all of the completed materials to the following address (be sure to include everything indicated
below):
LSAMP Office – ASCB - Room 323A
CSULA c/o M. Jefferson
5151 State University Drive
Los Angeles, CA 90032-8201

LSAMP UNDERGRADUATE ELIGIBILITY CRITERIA


Must be US citizen or permanent resident
Must have a declared science (biochemistry, biology, chemistry, exercise science, geology, microbiology, natural science,
physics), engineering (civil, computer science, electrical, mechanical, other), or mathematics (math) (SEM) major in GET

Must be working on first bachelor’s degree at CSU, Los Angeles

Must be enrolled at CSULA each AY quarter (excluding summer)

Must have demonstrated that you have faced specific educational, social or economic barriers in your pursuit of
higher education

Academic progress must be demonstrated each year by completion of requirements for major degree program and
progress toward graduation

Application must be complete with all components clearly readable (typed applications REQUIRED)

CUM GPA = 2.000 or higher to qualify for any program funding and priority registration

Active participation in program activities and completion of the LSAMP Report Form to qualify for any program
funding and priority registration

Demonstrated interest in a research career or graduate school to qualify for specific program funding

LSAMP CHECKLIST FOR COMPLETE APPLICATION
_____

Every question must be answered. (Note: your application is considered incomplete if any question is left blank.
Read questions carefully to avoid having your application rejected for inappropriate responses.)

_____

Information you provided is accurate according to GET.

_____

I understand that to fill in the specific checkboxes to many of the questions, I simply have to double click on the
boxes and chose a fill-in color.

_____

If Permanent Resident, you must include a copy of both sides of your PR card with your photo on it.

_____

All applications must include a printout of your Academic Year 13-14 and Financial Aid Summary 13-14 forms (see page
7 of this application for precise instructions on what each of these forms are and how to obtain them.)

CSU-LSAMP is supported by the National Science Foundation under Grant # HRD-1302873 and the CSU Office of the Chancellor.

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_____

Properly completed Academic Plan with required signatures (read and follow all instructions on top of 8).

_____

Academic Plan (p. 8) is signed by a major department faculty academic advisor or MEP advisor if engineering or
computer science major (plan ahead – application is unacceptable without faculty signature).

_____ Signed and dated Statement of Understanding (see p. 9)
_____ Arrange to have your digital photo taken by LSAMP Office Staff (Go to ASCB-323A or call 323/343-2095).

KEEP PAGES 1 & 2 FOR YOUR OWN RECORDS. SUBMIT ONLY APPLICATION (PAGES 3-9).

CSU-LSAMP is supported by the National Science Foundation under Grant # HRD-1302873 and the CSU Office of the Chancellor.

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CSULA LSAMP UNDERGRADUATE APPLICATION FORM
Please type information in right column
1)

First Name:

2)

Middle Initial (type none if no M.I.)

3)

Last Name:

4)

CIN (without dashes):

5)

SSN with dashes (required for
program incentives):

6)

Date of Birth (format = mm/dd/yyyy):

7)

Street Address (if you live in student
housing make sure you include both
your current address and permanent
address):

8)

Apartment # (type none, if none):

9)

City:

10)

State:

11)

Zip Code:

12)

Home phone # (e.g., 555-555-555):

13)

Cell phone # (type none if none):

14)

CSULA Email address (type userid):

15)

Personal Email address (type none
if none):

16)

Citizenship (if permanent resident,
must provide a copy of PR photo id
and type PR # in box provided):

@calstatela.edu

US citizen
Permanent Resident (PR) #:

17)

Gender:

Male

Female

18)

Ethnicity:

Hispanic or Latino/a

Not Hispanic or Latino/a

19)

Race (list provided by National
Science Foundation; check as many

Black or African American

Asian

CSU-LSAMP is supported by the National Science Foundation under Grant # HRD-1302873 and the CSU Office of the Chancellor.

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that apply; if you check other,
explain):

Native American Indian

Alaska Native

Native Hawaiian

White

Other Pacific Islander

Hispanic/Latino/a

Other
NONE
Hearing Impairment
20)

Disabilities (if you check other,
explain)

Visual Impairment
Mobility/Orthopedic Impairment
Other

21)

22)

23)

First Quarter and Year you enrolled
in classes at CSULA:
Quarter & Year you plan or hope to
graduate in your major from
CSULA:
Did you transfer to CSULA from
another college/university?

Yes (Indicate the name of school you transferred from)
No
First-time Freshman (0 college units earned)
Freshman (1 - 44 college units earned)

24)

Class Level (Use your GET access
to verify class level is correct
online):

Sophomore (45 - 89 college units earned)
Junior (90 – 134 college units earned)
Senior (135 or more college units earned)
Biochemistry (BIOC)

Major (Use your GET access to
verify your major is correct
online; submit a change of
major form to ADM 146 if
information is incorrect;
proper abbreviation for major
is provided; if declared DUAL
major, check one(s) that
25)
apply and use other, if one of
the dual majors is non-SEM;
note that one of the dual
majors must be indicated in
the right column to be
eligible for program; if you do
not verify that your major is
correct in GET, your
application will be rejected if
the major is different than

Biology (BIOL)
Chemistry (CHEM)
Civil Engineering (CE)
Computer Science (CS)
Electrical Engineering (EE)
Exercise Science (EXER)
Geology (GEOL)
Mathematics (MATH)
Mechanical Engineering (ME)
Microbiology (MICR)

CSU-LSAMP is supported by the National Science Foundation under Grant # HRD-1302873 and the CSU Office of the Chancellor.

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Natural Science (NATS)
Physics (PHYS)
what you checked here)

Other Engineering (ENGR)
Other:

Have you completed all lower
division MATH requirements (100
26)
and 200-level courses) required for
your major?
Have you completed all lower
division ENGNEERING or
27) SCIENCE requirements (100 and
200-level courses) required for your
major?
28)

Are you a new transfer student starting
in Summer or Fall Quarter 2013?

29)

Are you eligible to receive financial
aid?

30)

Are you receiving financial aid for
current year?

31)

32)

33)

34)

35)

36)
37)

If you are eligible to receive financial
aid but not receiving it, explain why.
Otherwise type N/A in right column
box.
If you are NOT eligible to receive
financial aid, explain why. Otherwise
type N/A in right column box.
What is your career goal? That is, what
do you want to do after you receive
your bachelor’s degree in science,
engineering or math?
Very briefly describe any opportunities
you have had to do research. If none,
type none in right column.
If your answer to question 34 was none,
please explain why – (e.g., have you not
pursued or investigated such
opportunities or have you no interest in
research or have you been too busy to
explore opportunities or some other
reason). If you have briefly described
research that you have participated in
for Q34, type N/A in right column.
Very briefly describe any internship
opportunities you have had. If none,
type none in right column.
If your answer to question 36 was none,

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

CSU-LSAMP is supported by the National Science Foundation under Grant # HRD-1302873 and the CSU Office of the Chancellor.

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please explain why – have you not
pursued or investigated such
opportunities or have you no interest in
doing internships or have you been too
busy to explore opportunities or is it too
early in your major to do an internship.
If you have briefly described internships
that you have participated in for Q36,
type N/A in right column.
38)

Are you interested in obtaining a
Masters degree?

39)

Are you interested in obtaining the
PhD?

Yes

Maybe

No
Yes

Maybe

No
0 hours, I do NOT work.
1-10 hours per week

40)

How many hours do you work per week
in a typical month?

11-20 hours per week
21-30 hours per week
31-40 hours per week
more than 40 hours per week

If you work, do you work on or off
41)
campus?
Are you interested in attending Summer
Internship Opportunities Program at
CSU, Sacramento in early December?
Are you interested in attending the
43) Graduate School Diversity Day
Program in November or April?
42)

I do NOT work.
work on campus

work off campus

Yes

Maybe

No
Yes

Maybe

No

Summarize the specific educational,
social or economic barriers you have
faced in your pursuit of higher
education. Failure to respond to this or
44) any other question on the application
form will result in rejection of your
application. Speaking a language other
than English is not considered an
educational, social or economic barrier.
45)

Describe how your participation in
CSU- LSAMP Undergraduate Program
will contribute to the program’s goals as
well as the goals of the National
Science Foundation (NSF) of
broadening participation by others
who may not be as well represented in
CSU-LSAMP is supported by the National Science Foundation under Grant # HRD-1302873 and the CSU Office of the Chancellor.

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specific science, engineering, and
mathematics (SEM) disciplines.
Are you interested in participating in
research training courses to learn about
46)
research careers and what research is all
about?

47)

Are you interested in applying in March or April
for the CSU LSAMP Scholars Program, which is
for students who are interested in pursuing
graduate studies, particularly the PhD, (must
have only one year of undergraduate work
remaining)? A separate application form
available in March is required, and up to $1000
may be awarded for the following academic year.

What science, engineering or
mathematics-related student clubs are
48)
you a member of? If none, type none in
the right column.
Are you interested in presenting
49) research at a professional meeting in
either oral or poster format in 2013-14?
50)

Are you interested in visiting graduate
schools in 2013-14?

Yes

Maybe

No

Yes

Maybe

No

Yes

Maybe

No
Yes

Maybe

No

Please note that it is your responsibility to notify us immediately, if any of this information changes.
FINANCIAL AID INFORMATION
Important – Read this page carefully even if you do NOT receive financial aid.
A. Regardless of whether or not you are receiving financial aid from CSULA, all applicants must PRINT
from your GET access the following TWO forms by following these instructions:
1. Use the GET Website (https://get.calstatela.edu) to obtain the following two forms:
Academic Year 13-14 form
Financial Aid Summary 13-14 form
2. Log into your GET account.
3. Go to the Student Services Home Link.
4. Go to FINANCES Link.
5. Look under FINANCIAL AID & click on VIEW MY FINANCIAL AID Link.
6. Select the appropriate year you want to look under.
7. Now you will be viewing the FINANCIAL AID SUMMARY 13-14. We refer to this page as the Academic
Year 13-14 because it shows everything that you are eligible to receive in 2013-2014 by each
quarter (PRINT THIS PAGE).
8. Next scroll down near bottom of that same page and click on FINANCIAL AID SUMMARY 13-14.
9. Now you will be viewing your FINANCIAL AID SUMMARY 13-14, which shows your UNMET NEED for
both AY13-14 and SU13 (PRINT THIS PAGE).
10. Submit the two pages that you just printed out to the LSAMP office (ASC-Wing B, Room 323A) with
the rest of your application.

B. If you are receiving financial aid from CSULA, and if you have no unmet need but have loans that you
have accepted as part of your financial aid packet, any funds that you may receive from this program
may result in a reduction in your loans received from Financial Aid. Remember, loans must be paid back
and receiving awards from this program will result in less money you will have to pay back (as long as
the information that you provided is accurate and approved by the Office of Financial Aid).

CSU-LSAMP is supported by the National Science Foundation under Grant # HRD-1302873 and the CSU Office of the Chancellor.

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C. If you are receiving financial aid from CSULA, and if you have no unmet need and no loans as part of
your financial aid package, we MAY NOT be able to provide you with any stipend for which you may be
eligible. The Financial Aid Office determines whether or not you are eligible for a stipend– LSAMP does
NOT control this decision. If you fall into this category, you may be eligible for other incentives.

CSU-LSAMP is supported by the National Science Foundation under Grant # HRD-1302873 and the CSU Office of the Chancellor.

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LSAMP ACADEMIC PLAN FOR CSULA PARTICIPANTS
(Complete this one year plan with an academic advisor listing when you will take specific requirements)
Please sign the form and have a faculty academic advisor also sign the form (see checklist for other
specifics on who can sign form). Provide all information requested. Indicate the total units that you will take
each quarter. Under the Course # column use the proper department abbreviations (see page 1 of the
Schedule of Classes) followed by the course number (For example, CHEM 101; BIOL 100A; ME 401; ENGR
300; CS 260; MICR 300; etc). Under the Units column, specify the number of units that the course is worth.
Academic progress is a requirement of LSAMP! *If not enrolled in SUMMER 2013 classes, explain what
you will be doing. THIS Page MUST BE TYPED, then printed out, and proper signatures obtained (see
checklist on page two)! Failure to follow these instructions will result in rejection of your application.

Student's Name: _______________________

Major: _______________

Minor (specify if any or indicate none if no minor): __________________
QTR/YR: SUMMER 2013*
Course #
Units

Total Units
QTR/YR: WINTER 2014
Course #
Units

Total Units

CIN: __________________
Date: __________________

QTR/YR: FALL 2013
Course #
Units

Total Units
QTR/YR: SPRING 2014
Course #
Units

Total Units

Your Signature: ___________________________

Academic Advisor's Signature: ___________________

Proposed Graduation Quarter & Year: _______

Current CUM GPA (look up in GET): __________________

CSU-LSAMP is supported by the National Science Foundation under Grant # HRD-1302873 and the CSU Office of the Chancellor.

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Passed WPE in ____________________________
___________________

Print Name of Faculty Advisor:

(If not yet taken, state NOT TAKEN on line above)

CSU-LSAMP is supported by the National Science Foundation under Grant # HRD-1302873 and the CSU Office of the Chancellor.

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During the academic year, we will email you a LSAMP REPORT FORM which must be completed to
determine possible eligibility for priority registration or stipends. You must submit the LSAMP REPORT
FORM by the deadline (which will be indicated on the form). Please note that in order to receive priority
registration for a given quarter, you must complete the LSAMP REPORT FORM by the deadline indicated
on the form. If you are eligible for a stipend during the 2013-2014 academic year, we will ask you to sign a
stipend form and a vendor form. We will also complete a Coordination of Aid (COA) form that must be
approved by the Office of Financial Aid. Please note that since stipends are based on your participation,
degree progress, and academic performance overall, stipends are not usually awarded until the end of
quarter or in many cases at the end of the academic year. The stipend form requires that we include the
following information (so complete the appropriate information and be certain to let us know if this
information changes during the year).

_____ I do NOT work on campus.

_____ I do work on campus in the following position:

Title of your position: ________________________________________

Name of Department: ________________________________________

Hourly compensation: _$__________________per hour_____________

Please read the statements below, print your name, sign where indicated, and date the form:
The information which I have submitted in my CSU-LSAMP Undergraduate Program Application is true and
accurate to the best of my knowledge. I understand that to track the progress of CSU-LSAMP participants
and to evaluate program effectiveness, CSU-LSAMP requires access to student information. The CSULSAMP program is required to report individual student data to the National Science Foundation including
social security number, ethnicity, GPA, and enrollment status. This information is also used to study
student transfer, retention, progression, and graduation. Photographs and research abstracts may also be
obtained for use by the CSU-LSAMP program in program dissemination materials such as websites,
newsletters, and reports. The student data are collected by the CSU-LSAMP Statewide Office at California
State University, Sacramento and each of the 22 affiliated Alliance CSU campuses.
I authorize release and use of personal information, as described above, to the CSU-LSAMP program. I
understand that this information is to be used solely for evaluating the impact and effectiveness of the
CSU-LSAMP program and that individual student data will not be released to parties other than those
directly involved with the program.
I also understand that when I submit abstracts, research papers, and give poster or oral presentations I
must properly acknowledge the CSU-LSAMP grant in the following format at the end of the abstract and on
the poster itself: Supported by NSF funds to CSU-LSAMP and Office of the Chancellor funds.
I have read and understand all of the statements above.
Printed Name of Applicant:

___________________________________________________________

Signature of Applicant:

___________________________________________________________

Today’s Date:

___________________________________________________________

CSU-LSAMP is supported by the National Science Foundation and the CSU Office of the Chancellor.

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CSU-LSAMP is supported by the National Science Foundation and the CSU Office of the Chancellor.

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