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BROOKHAVEN NATIONAL LABORATORY
SCIENCE EDUCATION CENTER
HIGH SCHOOL RESEARCH PROGRAM

Applicant Data

Applicant data are important in assessing the effectiveness of our efforts to solicit applications from a diverse population. Your com­pletion and submission of this form will assist us in this regard; however, if you decide not to do so, your choice will not affect our decision regarding your application. We appreciate your cooperation.

Name ____________________________

Date ____________________________

Ethnic group:
____ White (not Hispanic or Latino - a person having origins in any of the original peoples of Europe, North Africa or the Middle East)
____ Black or African American (not Hispanic or Latino - a person having origins in any of the Black racial Groups of Africa)
____ Hispanic or Latino (a person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin regardless of race)
____ Asian (not Hispanic or Latino - a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent)
_____American Indian or Alaskan Native (not Hispanic or Latino - a person having origins on any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition)
_____Native Hawaiian or other Pacific Islander (not Hispanic or Latino - a person having origins in Hawaii or the Pacific Islands)

Gender:_________

Physical/mental disability (physical or mental impairment that substantially limits one or more major activities--for example, blind­ness, deafness, or mobility impairment)
Yes     No

If Yes, explain:

PLEASE RETURN WITH APPLICATION

Last Modified: March 21, 2008
Please forward all questions about this site to: Sarah Maine

One of ten national laboratories overseen and primarily funded by the Office of Science of the U.S. Department of Energy (DOE), Brookhaven National Laboratory conducts research in the physical, biomedical, and environmental sciences, as well as in energy technologies and national security. Brookhaven Lab also builds and operates major scientific facilities available to university, industry and government researchers. Brookhaven is operated and managed for DOE’s Office of Science by Brookhaven Science Associates, a limited-liability company founded by Stony Brook University, the largest academic user of Laboratory facilities, and Battelle, a nonprofit, applied science and technology organization.

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