Please type or print in black ink. Print your last, first, and middle names in 1a:
1a._______________________________________________1b. Bring your Soc.sec.no. 11/14/09
2 Important:Your or your parents' e-mail address: _______________________________________
3. Home address______________________________________________________OH __________
4. Parents or guardians__________________________________5. Phone _____-_____-__________
6. Newspaper and city _______________________________________________________________
7. High school ________________________________________8. Phone _____-_____-__________
9. School address _____________________________________________________OH __________
10. Chemistry teacher _______________________________________________________________
11. Science or mathematics fields of interest in college. "A" for top choice.
A. _________________________ B. ________________________ C. ________________________
S1. I certify that I'm a high school senior and plan to graduate in ____________ and that the information contained in this application is complete and accurate. I understand (1) that the submission of inaccurate information is sufficient cause for disqualification for this contest and its prizes, and (2) that I must attend all events of the Contest between 10 AM and 4:30 PM to be eligible to receive the prizes.
Date_______________________Applicant signature_________________________________________
S2. I, the parent/guardian of this applicant, hereby authorize the release of the high school transcript and other information of the applicant to Ohio University and its representatives.
Date_________________________Parent/guardian signature__________________________________
12. Chemistry teacher or guidance counselor will complete the following: For each chemistry course taken by the applicant, show the following items: Course title, Grade, Date, Rank, Number of students in that class.
_______________________________________________________________________________
_______________________________________________________________________________
GPA_______ Rank______/______ SAT: Math _______ Verbal _______ SAT date_____________
ACT: Math ______ Engl ______ Read ______ S.R. ______ Comp _____ ACT date_____________
S3. I, the (circle one) chemistry teacher/guidance counselor, certify that the information for the applicant in item 12 is complete, correct, and up to date.
Date_________________________Signature_______________________________________________
Send (a) this completely and correctly filled and signed application, (b) an official transcript from your high school (with GPA, GPA scale, rank, SAT and/or ACT scores), (c) a letter of recommendation from a chemistry teacher, and (d) a $10 check payable to Ohio University, to reach Dr. James Tong, Department of Chemistry and Biochemistry, Ohio University, 136 Clippinger Labs, Athens OH 45701-2979, no later than November 9, 2009. If you can't mail the application materials before 11/9/09, email or phone Dr. Tong before 11/9/09 and mail him a check for $10, and ask your school to fax him at 740-593-0148 on or before 11/9/09 your application materials. For more information, send e-mail to tong@ohio.edu, fax 740-593-0148, or phone Dr. Tong at 740-593-1733.
Jimmy Tong modified this file (http://www.ohio.edu/chemcontest/apply.htm) on August 31, 2009.