Student Information

Permanent Address*
Alternate or Local Address

If you are a current UB student, use your address.
(xxx) xxx-xxxx
Date of Birth*
Legal Sex*
Race/Ethnicity (check all that apply)*

Academic Information

On a 4.0 scale

Honors, Scholarships and Awards Information

Please list your academic honors and scholarships, etc.


Non-UB students are required to send official academic transcripts to:

Dr. Letitia Thomas
LSAMP Program
222 Baldy Hall
Buffalo, NY 14260

UB students can upload an unofficial transcript below. Unofficial UB transcripts can be requested in the HUB Student Center

Upload Unofficial Transcript (UB students only)
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Please attach a resume to show your employment and extracurricular activities

Upload Resume*
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More About You

The following questions must be answered fully.


Please list the name of an individual from whom you will be requesting a reference. Provide their name and email address. Your reference will receive a link via email when you complete and submit this form.

Recommender Name*
Recommender 2 Name

Confirmations & Certifications

Please check the boxes to confirm that:*
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