| Name (Last, First, MI): | |
| Address (Street, City, State, Zip) | |
| Telephone Number (Area code + 7 digits) | |
| Email Address: | |
| Country of Citizenship | |
| Where do you currently teach? School, City, State | |
| What grades and subjects do you currently teach? | |
| Do you have special areas of interests or expertise as a teacher? | |
| Gender | Female
Male
Do not wish to report
|
| Ethnicity | Hispanic or Latino
NOT Hispanic or Latino
Do not wish to report
|
| Race (check all that apply) | Alaska Native
Asian
Black or African American
Native American
Native Hawaiian or Other Pacific Islander
White
Unknown
Do not wish to report
|
| Disability Status | Hearing Impairment
Visual Impairment
Mobility or Orthopedic Impairment
Other
None
Do not wish to report
|
| Do you have previous laboratory research experience? | None
Less than 50 hours
More than 50 hours
|
| Are there any other factors that should be considered when placing you in a specific laboratory or research experience? | |
| Indicate each RET location that interests you. | Milwaukee School of Engineering
University of Minnesota
|
| Please submit a one page typed cover letter indicating your interest in fluid power, why you are interested in participating in the CCEFP RET Program. | |
| Please submit a current resume | |
| Names, titles and email addresses of your references | |
|