The Timbuktu Academy - Online Application Form

(All fields must be fully completed.)

 

Dr 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

Southern University and A&M College

SUMMER BRIDGE INSTITUTE (SBI)
Under Graduate Research Program (URP) AA aaaaaaaaA(Check one or both)


Personal Data
(All fields must be fully completed.)

Name(last,first,middle)
Social Security Number:
E-Mail Address(Important):
Date of Birth:

Contact Information
(Enter Mailing Address and Telephone number.)
Street Name:
City:
State:
Zip Code:
Home Phone

Specify Gender
(Click to choose.)
Female
Male


Permanent Contact Information
(Enter permanent address and permanent contact phone number.)

Street Name:
City:
State:
Zip Code:
Contact Phone Number:

Ethnicity
(This optional information has no bearing on the selection process. It is strictly for statistical purpose only.)
African American
Asian American
Hispanic American
Native American
White American/Caucasian
Other


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

United States
Permanent Resident
Other


Education Record
(ATTACH A COPY OF AN OFFICIAL HIGH-SCHOOL TRANSCRIPT)

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

Current Grade
(LEGEND: HS. - High School *CO. - College *Sr. - Senior *Fr. - Freshman *So. - Sophomore * Jr. - Junior)
HS-Sr.
CO-Fr.
Co-So.
CO-Jr.
Co-Sr.


Parent / Guardian Information
MOTHER

Name:
Address (if different from above):
Daytime Phone Number:
Highest Grade completed:
FATHER
Name:
Address (If different from above):
Daytime Phone Number:
Highest Grade Completed:

ACT Scores
(You need to mail the original ACT score report)
Composite:
English:
Math:
Reading:
Sci. Reas.:

SAT Scores
(You need to mail the original SAT Score report)
Verabal:
Math:

Student
(Please enter the full name)
Name:
Date:

Parent/Guardian
(Please enter the full name)
Name:
Date:

References
(Please list below the names, title/affiliation, and office ohone number of the three 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.)

i) Name:
Title:
Telephone:
ii) Name:
Title:
Telephone:
iii) Name:
Title:
Telephone:

Essay
(Please describe your career goals, interest in science, and previous experience(science fairs/rallies,summer research,summer enrichment, etc.), if any.)
CHECK LIST
(Please mail the following document, after submitting this application.)

1. Official high school transcript.
2. Three letters of recommendation
3. ACT/SAT score report (all pages)
4. Resume (See sample resume on the Timbuktu website
5. SUBR Admission application, if not previously submitted.
APPLICATION DEADLINE: MAY 25, 2003 for SBI


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)




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