Funding Application/Award Form

________________________________________________________ _______________ Last Name First Middle University ID ______________________________________________________________________________ Address City State Zip ____________________________________ ______________________________ Date of Birth Place of Birth

_____________________________________________________________________________ Email Address

Degree Objective: Masters

Ph.D Degree Program:

Estimated Date of Program Completion: R

Are you a citizen of the United States?

If not, what type of visa do you hold? What country?

Rank your preference for funding. You will be considered for all awards for which you are eligible.

Tuition Scholarship Fellowship Traineeship

Teaching Asst. 50% time* 25% time** 33% time***

Research Asst. 50% time* 25% time** 33% time***

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Tuition Scholarship Fellowship Traineeship Teaching Asst. 50% time 25% time 33% time Research Asst. 50% time 25% time 33% time Select and Complete: Acad. Year 1st Semester 2nd Semester Summer

_____________________________________________ __________________ Signature of DEO/DGS Date