CSTEM Graduate Assistantship Application

Fill this form out completely. All academic references will be checked prior to approval of your assistantship. THIS DOCUMENT IS NOT AN APPLICATION TO THE GRADUATE SCHOOL. Your assistantship WILL NOT BE APPROVED UNTIL the graduate school has PROCESSED and ACCEPTED your application to them. Do NOT press the “SUBMIT” BUTTON UNTIL YOU HAVE COMPLETED THE ENTIRE FORM! Press the submit button only once; sometimes there is a time “lag” over the internet before your submission is confirmed.

Name*

First Last

UA Little Rock T#

Permanant Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Outside the United States please include your country code.

Primary Email*

Secondary Email

(If Available)

Current Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Outside the United States please include your country code.

I am a:

United States Citizen

Resident Alien (immigrant)

Non-Resident Alien (here on visa)

If you are a Non-Resident Alien, indicate your VISA Type:

I am a legal resident of the state of Arkansas:

Yes

No

Do you currently have a social security number (SSN)?

Yes, I have a SSN.

No, but I will apply for a SSN if awarded a Graduate Assistantship.

Section III – Academic Information

Academic Plans

Program

I am seeking admission for the:

Fall Semester

Spring Semester

Upload CV

Max. file size: 24 MB.

Academic Experience

List (in chronological order, MOST RECENT FIRST) all Colleges and Universities you have EVER attended:

College or University attended:

Dates attended: (mm/yyyy – mm/yyyy)

Degree conferred:

College or University attended:

Dates attended: (mm/yyyy – mm/yyyy)

Degree conferred:

College or University attended:

Dates attended: (mm/yyyy – mm/yyyy)

Degree conferred:

College or University attended:

Dates attended: (mm/yyyy – mm/yyyy)

Degree conferred:

List 3 personal references below. Each reference MUST come from a faculty member from one or more of the universities you have attended. The telephone number given for each reference CANNOT BE A HOME TELEPHONE NUMBER. The telephone number must be the “main” telephone number for the contact professor’s DEPARTMENT, and CANNOT BE A DIRECT LINE. Your application WILL BE DENIED if you include a home telephone number. Include the country code if foreign.

Reference 1

Please Include Full Name, Department Name, University Name, and Department Phone Number.

Reference 2

Please Include Full Name, Department Name, University Name, and Department Phone Number.

Reference 3

Please Include Full Name, Department Name, University Name, and Department Phone Number.

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