DIRECTIONS: 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.
Last Name:
First Name:
Middle Name:
Street Address:
City:
State or Province:
Country (use 3-letter code): 5-Digit Zip Code
Telephone Number (include country code if foreign):
Fax Number (include country code if foreign):
Enter your current email address:
Enter your secondary email address (if available):
Country (use 3-letter code) 5-Digit Zip Code
The items on this application concerning race, ethnic origin, gender, and physical disabilities will be used for affirmative action reporting purposes only.
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
I am: American Indian or Alaskan Native Asian or Pacific Islander Black, Non-Hispanic Caucasian, Non-Hispanic Hispanic
Male Female
I have disabilities which require special accomodation: Yes No
If yes, please list the disability or disabilities:
Please select from the list below. I am seeking a Ph.D. (we do NOT offer master's degrees) in:
Applied Bioscience Applied Chemistry Applied Computer Science Computational Science Engineering Science Applied Physics
I am seeking admission for the: Fall Semester Spring Semester
List any extracurricular activities you have and/or any academic honors you have received:
List your work experience in business, science, or teaching:
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:
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.
Full Name:
Department Name:
Name of University:
Department Telephone Number:
