SBI/URP 			
Diola Bagayoko, Ph.D., Director
Timbuktu Academy
Southern University and A & M College		
P. O. Box 11776 - Baton Rouge, LA 70813
Phone: (225) 771-2730    Fax: (225) 771-4341
e-mail: timbuktu.academy@grant.phys.subr.edu

		       Application Form 
		     The Timbuktu Academy
		Southern University and A&M College
		(All Fields must be fully completed)

------	Summer Brigde Institute	(SBI)
------	Undergraduate Research Program (URP)
(check one or both)


PERSONAL DATA

Name (last, first, middle):_________________________



Social Security No.:	  :----------------------



E-mail Address (Important)	



Date of Birth		:______________________________


Mailing Address		:_______________________________



City			:_____________________________


State			:____________________________



Zip Code		:____________________________


Home Phone		:(_____)__________________             


*Specify Gender		:Male_______Female________


Permanent Address(if different):___________________



City			:__________________________



State			:__________________________


Zip Code		:________________________	


Permanent Contact Phone Number:(______)_________			


*Ethnicity(Check all that apply):African American ______
                  		 Asian American   ______
				 Hispanic American______
				 Native American  ______
				 Caucasian______
				 Other _____________

*This optional information has no bearing on the selection process.  It is strictly for statistical purposes.

Citizenship			:U. S.
			         PermanentResident
				 Other_________
(MUST BE A U.S. CITIZEN OR PERMANENT RESIDENT)

EDUCATION RECORD

High School (2000-2001)		
Expected Graduation Date 	:GPA 				


(ATTACH A COPY OF AN OFFICIAL HIGH SCHOOL TRANSCRIPT)

(Intended) Major		:_______________

Current Grade			:_______________	


Select One			:HS-Sr. _______
				 CO-Fr. _______
				 CO-So. _______
				 CO-Jr. _______ 
				 CO-Sr. _______

LEGEND:  HS- High School  * CO - College  *  Sr. - Senior  *  Fr. -Freshman  *  So.- Sophomore  *  Jr. - Junior

PARENT/GUARDIAN INFORMATION

MOTHER				
Name				:								
Address (if different)		:



Daytime Phone Number		:(_____)_________

FATHER
Name				:

Address (if different)		: 

Daytime Phone Number		:(_____)_________

Highest grade completed by 
MOTHER				:

FATHER				:



ACT SCORES			:Composite _______

				 English   ________     

				 Math      _______

				 Reading: _______ 

				 Sci. Reas. _____

SAT				:Verbal ____  Math ____


MAIL COMPLETED APPLICATIONS TO:

Dr. Diola Bagayoko
Director, Timbuktu Academy
P. O. Box 11776
Baton Rouge, LA 70813

FOR OFFICE USE ONLY:

Date Received	: _________________

Status		: ________________________

Letter		:_________________________

APPLICATION DEADLINE:  MARCH 30, 2003 for SBI,  Applications are accepted year round for URP





Student's Signature 	:_____________________

Date			:_____________________

Parent's Signature	:_____________________

Date			:_____________________



APPLICATIONS ARE DEEMED INCOMPLETE UNLESS ACCOMPANIED BY A SHORT ESSAY, THREE LETTERS OF RECOMMENDATION, ACT/SAT SCORE REPORT, RESUME AND AN OFFICIAL HIGH SCHOOL TRANSCRIPT.


Please list below the name, title/affiliation, and office phone number of the three (3) individuals you have asked to write a letter of recommendation.  
NOTE:  INDIVIDUALS MUST BE HIGH SCHOOL OR COLLEGE SCIENCE, ENGLISH, MATHEMATICS, OR 
ENGINEERING TEACHERS/INSTRUCTORS.



Name			:
Title			:
Telephone		:


Name			:
Title			:
Telephone		:


Name			:
Title			:
Telephone		:




ESSAY




On a separate sheet, please describe your career goals, interest in science, and previous science experiences (science fairs/rallies, summer research, summer enrichment, etc.), if any.



CHECK LIST

This application must have the following documents attached:



1.	Official high school transcript
2.	Three letters of recommendation
3.	Essay (See Section Above)
4.	ACT/SAT score report (all pages)
5.	Resume'  (See sample resume' at our website 
	http://www.phys.subr.edu/timbuktu.htm)
6.	SUBR Admissions application, if not previously            submitted (for SBI applicants only)

APPLICATION DEADLINE:  MARCH 30, 2003  for SBI

The application and additional information on the Timbuktu Academy may also be obtained via the home page of the TimbuktuAcademy:
http://www.phys.subr.edu/timbuktu.htm





APPLICATIONS ARE DEEMED INCOMPLETE UNLESS ACCOMPANIED BY A SHORT ESSAY, THREE LETTERS OF 
RECOMMENDATION, ACT/SAT SCORE REPORT, RESUME AND AN OFFICIAL HIGH SCHOOL TRANSCRIPT.

FUNDED BY THE DEPARTMENT OF THE NAVY, OFFICE OF NAVAL RESEARCH (ONR)