Physics Research Experiences for
Undergraduates
                                                    University of Washington

                                                   Optional Information Form

The following information is requested so that we can meet Federal
reporting requirements.  Your responses will not affect the disposition of
your application in any way. Submission of this information is voluntary.


Applicant name:


Social security number:


Date of birth:


Sex:      (  ) Male        (  ) Female


Citizenship:     (  )  United States
                        (  )  Other (please specify)


Disabled:      (  )  Yes
                     (  )  No

If you are disabled, please describe your disability and any special
accommodations that might be required.  The University of Washington
Physics and Astronomy Building meets the latest ADA standards.






Are you a veteran?      (  )  Yes
                                    (  )  No


If yes, did you serve in Vietnam?     (  )  Yes
                                                          (  )  No



Ethnicity     (  )  American Indian or Alaskan native
                    (  )  Asian or Pacific Islander
                    (  )  Black
                    (  )  Hispanic
                    (  )  Caucasian (non Hispanic)




Please email this form to:

              uwreu@phys.washington.edu

or mail to:

              Research Experiences for Undergraduates
              c/o Maria Francom
              Institute for Nuclear Theory
              University of Washington
              Box 351550
              Seattle, WA 98195-1550