APPLICATION FOR STUDENT PARTICIPATION
In the MARC USTAR Program
For Academic Year 2011-2012
Grambling State University
P.O. Box 569, Grambling, Louisiana 71245
Telephone: (318) 274-4464     Fax: (318) 274-2724
Email: himaya@gram.edu
(click here PDF)

 
1.  *Name                 
                                      (Last)                                               (First)                                         (Middle)                                 (Maiden)
2.  *Campus Address:   Box No. 3.  *Campus Tel. # (
4.  Local Address:
                                  
    
                                                    (City)                                     (State)                     (Zip)
5.  *Email:
6.  *Local Phone: (    Cellular:  (
7.  *Parent/Guardian Name:
8.  Permanent Home Address:
             
                         (City)                            (State)                  (Zip)
9. Permanent Home Phone:  (
10.  *Legal Residence (state):   11.  *Citizenship:
12.  U.S.A. Permanent Residence (For non US citizen):   yes     no
13.  *Date of Birth:    
                                             (Month)                (Day)           (Year)
14.  Gender: 
15.  How do you describe yourself?
Black/Afro-American Mexican American/Chicano Hispanic or other Latino
Native American Oriental/Asian American Other (specify)
White/Caucasian Puerto Rican  
16. Rank in High School:

17. List all colleges /universities at which you have taken courses. Please include official sealed transcripts from each college attended.

College/University City/State Dates Attended (MM/DD/YYYY)
    From To
18.  Area of Study at GSU:
19.  Total number of credit hours remaining for graduation:
20.  Cumulative grade point average (CGPA):  At GSU       At other institutions
21.  Classification:
 
22.  Expected Graduation Date From GSU:

23.  Test Information (ACT or SAT)
ACT (Highest Scores)
English      Math      Reading      Science      Composite
SAT (Highest Scores)
Verbal       Math      Composite
 

24.  Scholastic Distinctions or honors
      
 
25.  Summer Internships/Coop
Institution Period

 

26.  Please provide two letters of recommendations in addition to the two Rating Forms Provided.  One recommendation should be from your research mentor while at summer research internship (if applicable).
List below two persons you have  asked to provide recommendation for you.

*Name Address/Telephone/Email
1. Address:
  Telephone: (
  Email:
2. Address:
  Telephone: (
  Email:

 

27. List all required Science and Math courses remaining to take for graduation. Please refer to your current transcript and current catalog. DO NOT GUESS.

Sem/Yr Course Name Course # Sem Hrs. Sem/Yr Course Name Course # Sem Hrs.

Total

 

28.  Immediate plans after graduation from Grambling:
A.MD/Ph.D. B.Ph.D. C.PharmD/Ph.D. D.M.D.  
E.MS F.PharmD G.Post Baccal. Prog H.Work I.No Plans

29.  If not immediately going to graduate school, when do you plan to go on to graduate or professional school?
Semester        Year
  

30.  List major extra curricular activities (sports, band, choir, athletics, clubs, and organizations you have been involved during your college years.)

Sem/Yr Activity/Org. Office Held University

 

31.  What will be your area of specialization in graduate or professional school?
 

32.  What do you plan on doing three years after graduation from GSU?

33.  What do you plan on doing ten years after graduation from GSU?

34.  Have you ever been dismissed, placed on probation, suspended from school, or convicted of a crime in a court of law?    yes      no      If yes, please explain.

 

35.  Work Experience
List all full and part-time jobs you have held.

Kind of work Employers Dates of Employment Hours  per week Weeks per year

 

36.  Personal Statement
In the following blank lines, please identify your lifetime career goal. Identify your strengths and weaknesses and your plan to overcome the weakness in order to reach your lifetime goal. The personal statement helps us in becoming acquainted with you as an individual in ways different from courses, grades, test scores, and other objective data (Limit it to 200 words (17 lines) (font size Arial 10 in the space provided below).
 

 

37.  Highest Degree Aspired to:
BS          MS          MD          Ph.D.          MD/Ph.D.
 

38. *Honor Code

Under the MARC U STAR system of self-government, each student is responsible for obeying and supporting enforcement of the Honor Code, which prohibits lying, cheating and/or stealing. Students also are responsible for abiding by Campus code, which prohibits conducting oneself in a manner that impairs significantly the welfare of the educational opportunities of others in the university community. Do you agree to uphold the Honor System?
yes      no 
  

39. *CERTIFICATION

I certify that all information in this application is accurate, complete, and honestly presented. I understand that any inaccurate or misleading information or omission will be reason for disqualification from further consideration of this application and will be cause for rescinding of the offer if discovered at a later date.

Name:     E-Signed     Date:

* = Required