Term Applying

TERM APPLYING:

YEAR______SPRING______SUMMER I______SUMMER II______FALL______

CIRCLE THE COLLEGE/UNIVERSITY FOR WHICH APPYING:

ASU PSC PTC SEARK UA UALR UAM UAPB

STUDENT INFORMATION (PLEASE PRINT CLEARLY):

NAME______, ______

(LAST NAME) (FIRST NAME) (MI)

SOCIAL SECURITY NUMBER:______DATE OF BIRTH: ______

GENDER: Male______Female______

HOME ADDRESS: ______

CITY:______

STATE:______ZIP:______

TELEPHONE NUMBERS: HOME (AREA CODE) ______-______-______CELL (AREA CODE) ______-______-______

E-MAIL ADDRESS:______

List ANY Recent/Current Medical Conditions or Concerns the ARK-LSAMP Staff should be aware of:______

______

Parent/Guardian Number (in case of emergency): Home:______Cell:______

HIGH SCHOOL INFORMATION:

NAME OF SCHOOL:______

CITY:______STATE:______

School Counselor’s Name:______TELEPHONE NUMBER (AREA CODE): ______-______-______

High School GPA:______ACT Composite: ______ACT English :______ACT Math:______ACT Reading:______

Relevant Courses Taken in High School-check ALL that apply:

Biology AP Biology Chemistry AP Chemistry Physics AP Physics Algebra I Algebra II

Geometry Adv. Geometry Trigonometry Calculus I Calculus II Basic Computer Other______

NOTE: The following information must be completed and/or submitted when applying for this program:

·  University Application/Admission

·  Financial Aid Packet

·  High School Transcript

·  Attach a brief essay (one page) stating your interest in pursuing a science, technology, engineering or math (STEM) major

For More Information, Please contact:

ASU / PSC / PTC / SEARK / UA / UALR / UAM / UAPB
Dr. Benjamin Ellis / Dr. Frank James / Dr. Ben Rains / Dr. Kaleybra Morehead / Dr. Karen Hodges / Dr. Jim Winter / Dr. Morris Bramlett / Ms. Marlo Thomas
(870)972-3277 / (50)-370-5216 / (501)812-2268 / (870)543-5963 / (479)575-5346 / (501) 569-8069 / (870) 460-1465 / (870) 575-7112
/ / / / / / /