Congressional Science Fellowship Application Congressional Science Fellowship Application Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Enter Email Confirm Email US Citizenship Status*---Select---CitizenPermanent ResidentOtherIf you selected "other" above, please describe your citizenship and/or US work status as related to this fellowship Other Scientific Society MembershipsIf more than one, separate with commas. Ph.D. Status* ReferencesPlease note, three letters of recommendation are required to complete your application. Once you complete this form, you will receive an email with a link to send to your three references. It is your responsibility to ensure that all three of your references submit their letters before the deadline of 15 January 2024. Full Name of First Reference* Email of First Reference* PhoneFull Name of Second Reference* Email of Second Reference* Phone of Second ReferenceFull Name of Third Reference* Email of Third Reference* Phone of Third ReferenceWhere did you hear about AGU's Congressional Science Fellowship?Upload application files Browse your local file system for application files.Curriculum Vitae*Accepted file types: txt, doc, docx, pdf, Max. file size: 50 MB.Letter of Intent*Accepted file types: txt, doc, docx, pdf, Max. file size: 50 MB.Professional Conduct Disclosure FormProfessional Conduct Disclosure*Have you been subject of a filed allegation, complaint, investigation, sanction or other legal, civil or institutional proceeding, where there was a finding of misconduct; or, are you currently the subject of such an allegation, complaint, or investigation in which your professional conduct is at issue? No Yes [If yes, you will be contacted for a confidential discussion of the details of the complaint.] Optional Demographic InformationWe are asking for voluntary demographic information to see how AGU is doing in our attempt to recruit a diverse applicant pool. Individual demographic information is not shared with the selection committee at any point in the application or selection process.Race/Ethnicity (select as many as apply): Asian or Asian American Black, African, African-American, or Afro-Caribbean Hispanic, Latinx, Latino, Latina, or Spanish Origin Indigenous Peoples Native Hawaiian or Other Pacific Islander Native of Indian subcontinent Middle Eastern or North African White, Euro-American, or European Not listed Prefer not to say If you selected "Not Listed" and would like to self-describe, please do so here. Gender Female Male Non-binary Prefer to self-describe Prefer not to answer If you chose "Prefer to self-describe", please do so here. Do you identify as transgender? Yes No Prefer not to say Do you identify as: Heterosexual Homosexual Queer Bisexual Pansexual Prefer to self-describe Prefer not to say If you chose "Prefer to self-describe", please do so here. Certification*The undersigned hereby affirms that he/she has read, understands, and agrees to comply with the AGU Scientific Integrity and Professional Ethics Policy, including its Code of Conduct, and other policies and procedures established by AGU, as amended from time to time. By signing this document, I certify that, to the best of my knowledge, the above response and all information provided by me related to this Professional Conduct Disclosure Form are truthful, accurate, and complete, and I agree to notify AGU promptly of any material changes required in my responses to the above question. I acknowledge that failure to comply with AGU’s Scientific Integrity and Professional Ethics Policy, including its Code of Conduct, may result in my ineligibility to receive, or revocation of, any AGU award, honor, other type of AGU recognition, or governance position, and is grounds for potential sanctions against me. By clicking this both you certify that you understand and agree to the above conditions. PhoneThis field is for validation purposes and should be left unchanged.
