Date: ________________ Soc Sec #: ___________________
Last Name, First Name, M.I.: ________________________________________________________
Present Address: ___________ ______________________________
City, State & Zip: _________________ _______________________
Permanent Address: _____________________ _________________
City, State & Zip: ___________________________ ______________
Place and date of birth _____________________ Citizenship ______
List in order all institutions of college or university standing which you have attended:
Name of Institution Dates Attended Degree Received Year
_______________________ __________________ _________________
_______________________ __________________ _________________
_______________________ __________________ _________________
Undergraduate major subject _______________________ Minor subject ______
Graduate work to date, major subject _____________________
Minor subject _____________________
Have you ever been on probation or found it necessary to withdraw temporarily for academic reasons?____
If so, explain in full on the back of this sheet.
Numerical rank or percentile rank in graduating class ___________________________________________
Advanced degree sought at the University of Arizona ______________
Proposed major subject__________
What is your specific interest in these fields (high school teaching, college teaching, academic research, government, business, industry, etc.)? ______________________________________________________
If both were available, would you prefer a teaching or research assistantship?_________________________
List titles of all publications (including thesis titles), giving full
bibliographic references: ________________________________
_____________________________________________________
_____________________________________________________
List all teaching and other professional positions held to date, beginning
with the most recent:
Employer Position Dates
______________________ _______________________ ____________
______________________ _______________________ ____________
______________________ _______________________ ____________
List all honors, scholarships, prizes, honorary societies, etc. _______________________________________
_____________________________________________________________________________________
A number of departments pay serious attention to professionally related experience and many have an affirmative action policy relative to minority groups. If you care to supply information on either of these matters, please do so on the back of this page or in a separate letter.
List the names and addresses of three persons who have been asked to write directly to the Head of the Department in support of this application. (It is the applicant's responsibility to see that letters of recommendation are sent. This application will not be considered until such letters are received.)
______________________________________________
______________________________________________
______________________________________________
Applicant's signature____________________________________
The University of Arizona is an EEO/AA Employer and does not discriminate on the basis of sex, race, religion, color, national origin, Vietnam Era veterans' status , or handicapping condition in its admission, employment and educational programs or activities. Inquiries may be referred to Dr. Jean Kearns, Assistant Executive Vice President, Administration 503, phone 626-3081