LSAMP Application Form

First Name:      Middle Initial:      Last Name:

Email:      Scholarship Program :

Disciplines covered: Actuarial Science, Biology, Chemistry/Fermentation Science, Computer Science, Environmental Science, Geology, Mathematical Sciences, and Physics and Astronomy
Major/Classification (Freshman, Sophomore, Junior, or Senior) Ex. Chemistry/Freshman:


Cell Phone:

Gender:      Ethnicity:

Address Information
Street Address:

City:      State:

Zip Code:

Previous School Information
Type of School      School or College Name:

County (ex. Watauga):

Information regarding the two references
First Name of Reference 1      Last Name of Reference 1:

Phone Number of Reference 1:      Email of Reference 1:

First Name of Reference 2:      Last Name of Reference 2:

Phone Number of Reference 2:      Email of Reference 2:

Files to upload

*The only acceptable file types is pdf (.pdf). You need to make two PDF files to submit:

Upload ONE PDF file for your Cover Letter and Essay combined:

LSAMP Scholarship Program

Appalachian State University

Contact Information

Program Directors

LSAMP Application Form