NASA CONNECTICUTT SPACE GRANT CONSORTIUM Applicant Contact and Demographic Information *Please type Contact Information Name College Address Home Address Phone Official School Email Address Institution Universities: Community Colleges: ☐ Central Connecticut State University ☐ Capital Community College ☐ Eastern Connecticut State University ☐ Gateway Community College ☐ Fairfield University ☐ Housatonic Community College ☐ Southern Connecticut State University ☐ Manchester CT Community College ☐ Trinity College ☐ Middlesex Community College ☐ University of Bridgeport ☐ Naugatuck Valley Community College ☐ University of Connecticut ☐ Northwestern CT Community College ☐ University of Connecticut Health Center ☐ Norwalk Community College ☐ University of Hartford ☐ Quinebaug Valley Community College ☐ University of New Haven ☐ Three Rivers Community College ☐ Wesleyan University ☐ Tunxis Community College ☐ Yale University Optional Information Note: This information is being requested to help CT Space Grant Consortium comply with NASA reporting requirements Thank you for aiding us in the collection of this data Gender: ☐ Male ☐ Female Ethnicity: ☐ Hispanic or Latino ☐ Non-Hispanic or Latino ☐ Other: Race: ☐African American ☐Caucasian ☐Native American ☐Pacific Islander ☐Other: Person with Disability: ☐ Yes * ☐ No *To answer ‘Yes’, the applicant must have a physical or mental impairment that substantially limits one or more major life activities and have a record of this impairment NASA CT SPACE GRANT CONSORTIUM 203 Dana Hall, University of Hartford (Lead Institution), 200 Bloomfield Avenue, West Hartford, CT 06117 860.768.4813 ctspgrant@hartford.edu www.ctspacegrant.org @CTSpaceGrant