THE UNDERGRADUATE SUMMER SCIENCE ENRICHMENT PROGRAM
PERSONAL INFORMATION
Last Name
First Name
Middle Name
Social Security Number
Telephone
Email Address
Present Mailing Address
Street
Apt Number
City
State
Zip Code
Age
Date of Birth
Sex Male | Female
Marital Status: Never Married | Married | Separated | Divorced
Racial/Ethnic Origin
Disadvantage
Permanent Mailing Address
Apt #
Are you an Arkansas Resident? Yes | No
For emergency purposes list contact person:
Name
Address
Relationship
PROGRAM SELECTION
Which program are you interested in attending?
Phase I Phase II
If you are interested in USSEP Phase II, have you taken any of the Health Professions Admissions Tests?
Yes No
If yes, which test(s) and when?
EDUCATION
Current University/College Name and Address:
Anticipated Graduation (Yr)
Overall GPA Science GPA
Major
Minor
Current Classification
List in chronological order, all universities attended, ending with present university/college.
University
Dates Attended
Degree
Have you participated in any minority/disadvantaged recruitment program before?
Yes | No
If yes, list program, dates, purpose and location:
List any extracurricular activities or organizations that you are involved with:
CAREER ASPIRATIONS
What are your career choices at the present time?
First
Second
ESSAY
In the place provide below type a 250 word personal statement explaining your reasons for applying to this program and future plans.
Certification and Signature
I certify that the information supplied in this application is complete and accurate to the best of my knowledge.
Signature
