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

(If you experience any problems with the application,click here for 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:   yes     no
12.  U.S.A. Permanent Residence (For non US citizen):   yes     no
13.  *Date of Birth:    
                                             (Month)                (Day)           (Year)
14.  Gender:   M     F
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.  Major at GSU: 19.  Minor at GSU (if applicable):
20.  Academic Advisor Name:
21.  Total number of credit hours remaining for graduation:
20.  Cumulative grade point average (CGPA):  At GSU       At other institutions (if applicable):
23.  Classification:
 
24.  Expected Graduation Date (MM/YY):
     Cumulative Number of Credit Hours Completed in Math and Sciences:
     Cumulative GPA in all Completed Math and Science Courses:

     (Total quality points in all math & science courses divided by total math & science credit hours attempted)

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

26.  Scholastic Distinctions or honors
      
 
27.  Summer Research Internships/Coop Experience
Institution - Location Period (From - To)

 

28.  Please provide two Teacher Evaluation (Rating Forms). One form should be from your research mentor while at summer research internship (SRI), if applicable. If not applicable, both forms should be from your math/science instructors with Ph.D.

*Name of Recommender Telephone/Email
1. Telephone: (
  Email:
2. Telephone: (
  Email:

 

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

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

Total

 

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

31.  If not immediately going to Ph.D. program, when do you plan to go?
Semester        Year
  

32.  List major extracurricular activities Honor College, professional society (ACS/ACM) (NASBE), Honor Society, (sports, band, choir, athletics, clubs, and organizations you have been involved during your college years.), Academia clubs (biology, chemistry, math & physics), etc.

Sem/Yr Activity/Org. Office Held University

 

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

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

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

36.  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.

 

37.  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

 

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

39. *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 
  

40. *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:

41.  Personal Statement
In the following blank space below, 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.  Please type your personal statement and limit to the space provided below (font size Arial 11).
 

 

* = Required

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