Louis Stokes-Alliance for Minority Participation



DATE OF APPLICATION: ________________

CIRCLE THE COLLEGE/UNIVERSITY FOR WHICH APPLYING:

ASU PSC PTC SEARK UA UALR UAM UAPB

STUDENT INFORMATION (PLEASE PRINT CLEARLY):

NAME__________________________________ __________________________________ ____________

(LAST NAME) (FIRST NAME) (MI)

DATE OF BIRTH: _______________GENDER: Male_____ Female_____ SS NUMBER__________________

HOME ADDRESS: ______________________________________________________

CITY:_______________________________________ STATE:_________ZIP:_________

TELEPHONE NUMBERS: HOME (AREA CODE) ______-______-______ CELL (AREA CODE) ________-________-_________

E-MAIL ADDRESS:______________________________________ (print clearly)

PROPOSED MAJOR: ETHNICITY (circle all that apply):

African-American, Hispanic American, Native American, Alaskan Native, Native Pacific Islander.

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

____________________________________________________________________________________

Parent/Guardian NAME _______________________________________________ (in case of emergency)

Parent/Guardian NUMBER 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:________

ACT Science: ___________ ACT Writing: _________

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 submitted when applying for this program:

• University Application/Admission

• Financial Aid Forms (if you want to apply for other forms of financial aid)

• High School Transcript

• Attach a brief essay (one page) stating your interest in pursuing a Science, Technology, Engineering or Math (STEM) major

IF APPLYING TO UALR, SEND THIS APPLICATION AND YOUR ESSAY TO DR. JIM WINTER, LSAMP, UNIVERSITY OF ARKANSAS AT LITTLE ROCK, 2801 SOUTH UNIVERSITY, LITTLE ROCK, ARKANSAS 72204

APPLY TO UALR ONLINE AT: < > (Click on “Apply Now.” Note that you must pay a $40 application fee, though you can start the process and save the form until later.)

IF YOU WANT TO APPLY FOR OTHER FINANCIAL AID, MORE INFORMATION IS AVAILABLE AT: —especially note the scholarship deadlines.

For More Information, Please contact:

| | | | | | | | |

|[pic] | |Pulaski |[pic] |[pic] | | |[pic] |

| |[pic] |Tech | | |[pic] |UCA | |

| | | | | |Dr. Janet Lanza | | |

|Dr. Hashim Ali |Dr. Frank James |Dr. Ben Rains |Dr. Kaleybra Morehead |Mr. Thomas Carter |Dr. Jim Winter |New Member |Dr. Anissa Buckner|

|(870) 972-3215 |(501) 370-5216 |(501) 812-2268 |(870) 543-5963 |(479) 575-5346 |(501) 569-3500 | |(870) 575-7113 |

| | | | | |(501) 569-8069 | | |

| | | | | |jxlanza@ualr.edu| | |

|hali@astate.edu |fjames@philander.edu |brains@pulaskitech.ed|kmorehead@seark.edu |tic@uark.edu |jdwinter@ualr.ed| |bucknera@uapb.edu |

| | |u | | |u | | |

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DEADLINE: Open

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