Psychology Program Supplemental Application Form

Deadline: February 1, 2013 for Fall 2013 Admission

Ph.D. Program in Clinical-Community Psychology

Please type or print legibly

BE ABSOLUTELY SURE TO FOLLOW ALL APPLICATION PROCEDURES OUTLINED ON THE WEBSITE FOR THE PROGRAM

Last Name / First Name / Middle Initial
Address / Address Continued / City, State, Zip
Home Phone and Hours Available / Other Phone and Hours Available / Fax Number
Email Address / Social Security Number
OPTIONAL
/ Are you an Alaska resident?
Yes No
Lived in Alaska since:
Undergraduate Degree, Major, and University / Undergraduate GPA Overall / Undergraduate GPA for Major only
Graduate Degree, Field, and University ** / Graduate Degree GPA ** / Non-Degree Graduate Courses and University
GRE Raw Scores, Date Taken – OPTIONAL
Verbal:
Quantitative:
Analytical: / GRE Percentiles – OPTIONAL
Verbal:
Quantitative:
Analytical: / Psychology GRE Scores and Date Taken – OPTIONAL
Required Coursework Completed?
abnormal psychology
statistics
research methods / Completed at least one of the following?
clinical psychology
community psychology
social psychology
personality theories / Ethnicity or other Diversity Membership –OPTIONAL
Name and Email of Reference #1 (Academic Advisor) / Name and Email of Reference #2 (Instructor) / Name and Email of Reference #3 (Supervisor)
Number of years of relevant post-master’s degree work experience **: / Type of post-master’s degree work, including position title **? / Licensure in psychology or counseling **:
Psychological Associate: #
Professional Counselor: #
Marriage and Family Therapy: #
Preferred Campus:
CHOOSE ONLY ONE BOX
Resident at UA Fairbanks
Resident at UA Anchorage
No preference of Residence -either UAF or UAA / If accepted, is financial assistance needed?
Yes No / Assistantship Preferences:
Teaching assistantship
Research assistantship
No preference

**Required for Advanced Cohort Only

Required MaterialsChecklist

Complete application packets must be sent to the UAF Program Coordinatorand the UAA Program Coordinator. Please complete the following checklist to assure that your two application packets contain the information and materials required.

Material or Information Required / Check to indicate that the required materials were sent to:
UAF Program Coordinator / UAA Program Coordinator
Official UAF Application form retrieved from
Do not apply on-line to UAA – see website for further instruction on applying to UAF.
$60 application fee payment to each campus
Copy of a completed Psychology Program Supplemental Application Form
Original transcripts sent directly from your prior universities
Course Equivalency Form (advanced cohort only)
Copies of a professional vita
Letter of Intent
Reference Rating Form from an advisor in a signed, sealed envelope
Letter of support from same advisor sending Reference Rating Form
Reference Rating Form from instructor in a signed, sealed envelope
Letter of support from same instructor sending Reference Rating Form
Reference Rating Form from supervisor in a signed, sealed envelope
Letter of support from supervisorsending Reference Rating Form
A stamped self-addressed postcard
Disclosure Form

Optional Additional Materials Included (please check):

GRE scores (copies in both application packets; original mailed directly to the UAF Office of

Admissions).

Reprints or preprints of publications and presentations.

Copy of the relevant licenses.

Criminal Background Check (required for applicants given an offer of admission).

Other, specify:

Verify with your signature below that

you have reviewed all directions about the application and screening process for the PhD Program in Clinical-Community Psychology with an Indigenous and Rural Emphasisas posted on the program website;

you understand the application process;

you understand that you waive your right to view your Letters of Support and Reference Rating Forms;

you understand the selection process;

you understand that an in-person interview is required for all finalists;

you understand that a criminal background check will be required and obtained by the university before final admission the program;

you understand that you have to submit two application packets, one to the UAF Program Coordinator and one to the UAA Program Coordinator.

Signature: ______Date: ______