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AGEP STRIDES Participant Application
Part I

The application contains two parts. In Part I, we ask applicants for information about Race/Ethnicity, Residential Status, Institutional Status, and Ph.D. Candidacy at the time of application submission to determine candidate eligibility. The estimated time of completion of Part I is about 30 minutes.

Please provide the following information requested in the prompts below.

First Name

Middle Initial

Last Name

Email Address

Re-enter Email Address

Mobile Phone Number

Mailing Address Line 1

Mailing Address Line 2

City

State

Zip Code

Are you currently a:

Ph.D. Student?
Postdoctoral Scholar?

At which university is your current enrollment (Ph.D. student) or appointment (postdoctoral researcher)?

Texas Southern University
University of Houston
Rice University

What is your department? Please EXCLUDE "department of" from the name (i.e., list "Computer Science" rather than "Department of Computer Science").

With which ethnicity do you personally identify?

Hispanic/Latinx
Not Hispanic/Latinx
Prefer Not to Respond

With which race(s) do you personally identify? Please check all that apply.

Asian
Black or African American
Native American or Native Alaskan
Native Hawaiian or Pacific Islander
White
Another Race Not Listed Here
Prefer Not To Respond

Do you identify as a person with a disability (a physical or mental difficulty that substantially limits one or more major life activities)?

Yes
No
Prefer Not to Respond

Identify your gender within the construct of your choice in the field provided below. Please leave the field blank if you would prefer not to identify your gender.

Are you:

A U.S. Citizen?
A U.S. Permanent Resident?
A U.S. National (a native resident of a commonwealth or territory of the U.S.)?
Not a U.S. Citizen, Permanent Resident, or National?
Prefer Not to Respond

What is your level of interest in a career in the STEM academy (i.e., as a STEM faculty member at an institution of higher education)?

Not At All Interested
Somewhat Disinterested
Neither Interested Nor Disinterested
Somewhat Interested
Extremely Interested

How did you learn about AGEP STRIDES?

Email From AGEP STRIDES Team
Flyer
Peer (Another Student or Postdoc)
Social Media
Your Faculty Advisor/Sponsor
Other Source