Name
Permanent Address
City
State
Permanent Phone Number
SSN#
Local address
City
State
Local
Phone Number
Cell)
Parent/Guardian Address
Emergency Contact:
Name
Relationship
Phone #
Sex:
Date of Birth
Temple Email
Race/Ethnicity:
African American
Asian-American/Pacific Islander
Latino/Latino American
Native American/Alaskan
Caucasian
Other
Citizenship:
U.S. Citizen
Permanent Resident
Other
II. ACADEMIC BACKGROUND
Anticipated
Graduation Date:
Semester:
Year:
SAT scores:
M:
V:
Undergraduate Major(s)
Minor(s):
Proposed Graduate School Major/Discipline
List any previous research experience (including name of program, institution, faculty member or advisor,
and research title).
Please attach a resume listing your academic and
extracurricular awards, honors, and scholarships you have received.
Also include the academic/campus organizations and activities in which
you hold membership or participate, as well as work/volunteer
experience, and other relevant information.
Check any of the following programs in which you are,
or have, participated (if the program was not at Temple, please list
include the name of the institution):
Educational Services Component
Act 101
Student Support Services Program
Upward Bound
University Honors Program
Talent Search
Gear Up
Academic Department Honors Program
Alliance for Minority Participation
Learning Communities
Summer Research Opportunity Program
Math Science Upward Bound
Others
How did you first learn of the McNair Program? (If from a professor, please give name and department.)
III. FAMILY INFORMATION
Did you apply for financial aid for the 2002-2003 school year?
Yes
No
For financial aid
purposes, are you considered dependent or independent? If dependent,
complete Section A below; if independent complete Section B below.
A
How many people
live in your parents' household, including yourself?
Yes
No
B
Did your parents
claim you on their 2002 tax return?
If yes, complete
section A across.
How many people live in
your household, including yourself?
Yes
No
You must
submit a copy of your 2002 Federal Tax Return, along with your FAFSA
(due March 1, 2004. If you did not file taxes for the year 2002,
attach proof of income for that year.
A
Does your family receive assistance
from any of the following sources?
B
Does your family receive assistance
from any of the following sources?
Please indicate your parents’ level of educational
achievement.
Educational Attainment of Mother:
Highest Grade completed:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
College Degree Earned, if Any:
Associates
Bachelors
Masters
Doctorate
Unknown
Educational Attainment of Father:
Highest Grade completed:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
College Degree Earned, if Any:
Associates
Bachelors
Masters
Doctorate
Unknown
Additional Family Background (optional):
What is your marital status?
Married
Single
Divorced
Separated
Number of children
IV. RECOMMENDATIONS: Attached to this
application are two recommendation forms. Both recommendations must be
from faculty. Each member is required to send the form directly to the
McNair Program Office. In the space below, please list the names,
titles, addresses, and telephone numbers of your recommenders.
Recommender 1:
Name
Title
Department Name
Phone Number
Recommender 2:
Name
Title
Department Name
Phone Number
Recommender 3:
Name
Title
Department Name
Phone Number
V. PERSONAL STATEMENT:
On a separate sheet
of paper, please explain your career and academic goals, and how you
see participation in the McNair program as a means to fulfilling these
goals. Your statement should be typed on a maximum of two pages.
My signature below
indicates that, to the best of my knowledge, the information given on
this application is true and accurate. Additionally, I authorize
Temple University’s offices, including the Office of Student Financial
Services, Registrar, Academic Advising, and Dead of Students, to
provide the McNair Program with information about my financial and
academic status.
Signature
(Please type your name)
Date
(Please type the date)
