Name:

Home Address:

Home Telephone:

Work Address:

Work Telephone:

E-mail:

Online Courses taken at UALR:

Professional Goal: Briefly describe your goals upon completion of this degree, including type of agency, target population you would like to teach as an Orientation & Mobility instructor or a Rehabilitation Teacher etc.:

-Enclosed is a signed copy of the UALR-RSA Scholarship Agreement form

-Enclosed is a signed copy of the Certification of Eligibility form

____________________________________
(Scholar's Signature)

_________________
(Date)