NCAS-M Student Contact Form Step 1 of 2 50% Are you updating your current contact form?*YesNoCitizenship*Please indicate your citizenship status.US CitizenNot US CitizenI am sorry, this opportunity is only available for US Citizens. General InformationDate*Date Contact Form is completed. Date Format: MM slash DD slash YYYY Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Initial Last Suffix Current AddressIdentify your local/school address (e.g. dorm address) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Permanent Address*Identify your permanent/home mailing address (e.g. Parent's address) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell/Mobile Phone*Home PhonePreferred Phone Number*Cell/Mobile PhoneHome PhoneSchool Email* Enter Email Confirm Email Personal Email* Enter Email Confirm Email Preferred Email Address*School emailPersonal emailEducation InformationStudent ID*Your ID number from your home institution.Home Institution*Institution that you are attending.Select home institutionFort Valley State UniversityHoward UniversityJackson State UniversityPennsylvania State UniversitySan Diego State UniversitySan Jose State UniversityTuskegee UniversityUniversidad MetropolitanaUniversity of Albany State University of NYUniversity of Maryland Baltimore CountyUniversity of Maryland College ParkUniversity of Puerto Rico MayaguezUniversity of Texas El PasoPhotoYour image will displayed on the NCAS-M webpage under the Cohort you are assigned too. This is a request and not a requirement. Expected Graduation Date* Date Format: MM slash DD slash YYYY Student Classification*Undergraduate studentGraduate studentCurrent Student Level*Freshmen (Undergraduate Student)Sophomore (Undergraduate Student)Junior (Undergraduate Student)Senior (Undergraduate Student)Master's (Graduate Student)PhD (Graduate Student)Major*NCAS-M Faculty Advisor*Select faculty advisorTerri Adams, PhDJuan Arratia, PhDRoy Armstrong, PhDSen Chiao, PhDBelay Demoz, PhDYasmín Detrés, PhDSonya Smith, PhDGamal El Afandi, PhDJoseph Essamuah-Quansah, PhDMehri Fadavi, PhDSouleymane Fall, PhDRosa M. Fitzgerald, PhDJose D Fuentes, PhDThomas E. Gill, PhDCharles Ichoku, PhDEverette Joseph, PhDRicardo Kendi Sakai, PhDHaydar Kurban, PhDSiwei Li, PhDXin-Zhong Liang, PhDDuanjun Lu, PhDCeleste Malone, PhDQilong Min, PhDVernon R. Morris, PhDRemata S. Reddy, PhDSamuel Shen, PhDHari P. Singh, PhDWilliam Stockwell, PhDCarolyn Stroman, PhDTia C. M. Tyree, PhDLoren D. White, PhDOther Faculty Advisor Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix NOAA Mentor Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix NOAA Mentor Line OfficeSelect line officeCORP SVCSNESDISNMAONMFSNoneNOSNWSOARUNSPECIFIEDUSAODemographic InformationCitizenship Verification*Please indicate documentation that will be/has been provided to verify US citizenship.Select verification typeValid USA PassportUSA Birth Certificate with Government Issued Picture IDValid USA Naturalization Certificate of CitizenshipDocumentation File(s)*Upload a copy of the documentation you identified as citizenship verification. Drop files here or Hispanic/Latino Ethnicity*Please indicate whether you identify as Hispanic or Latino.SelectYesNoDecline to answerDate of Birth* Date Format: MM slash DD slash YYYY Race*Check all that apply. Black/African American White/Caucasian Asian American Indian/Alaska Native Native Hawaiian/Pacific Islander Decline to answer Gender*Check the box in which you identify.MaleFemalePrefer Not to AnswerEmergency ContactName of Emergency Contact* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Emergency Contact Phone*Relationship to Emergency Contact*SignatureSignature*This digital signature is a confirmation of the accuracy of the information listed on this form.
