ILLINOIS STATE UNIVERSITY



ILLINOIS STATE UNIVERSITYDepartment of PsychologyEdwin A. Payne Memorial AwardApplication Deadline: April 1Type in the required information in the boxes, which will expand as needed. Email electronic copies of the completed application and other required materials electronically to the Awards Committee Chair at jeffreywagman@illinoisstate.edu.Name FORMTEXT ?????Date FORMTEXT ?????Local Street Address FORMTEXT ?????City, State, Zip Code FORMTEXT ?????University ID FORMTEXT ?????Phone FORMTEXT ?????Colleges or Universities AttendedAttendance DatesSchool:From (MM/YY)Until (MM/YY) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Psychology-related Work ExperienceEmployment DatesOrganization and job title:From (MM/YY)Until (MM/YY) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Extracurricular Activities During CollegeActivity DatesOrganization or activity (note any office held):From (MM/YY)Until (MM/YY) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Cumulative GPA FORMTEXT ?????Last semester GPA FORMTEXT ?????Psychology GPA FORMTEXT ????? based on FORMTEXT ????? hours.Provide a brief statement about why you believe the Department of Psychology should award you the Edwin Payne Memorial Award. FORMTEXT ?????? I certify that the information on this application is factual and true to accurate to the best of my knowledge.Date: FORMTEXT ?????The following documents should be submitted to the department’s Awards Committee Chair at jeffreywagman@illinoisstate.edu:A completed application;A current Academic Progress Summary;Two (2) letters of recommendation, of which at least one letter must be from an Illinois State Pychology faculty member; andEvidence of scholarly and/or professional activity (e.g., honors thesis, independent study project, PSY 331 report, convention paper, publication, term paper or letter from supervisor in any activity related to professional psychology such as PATH Crisis Center, OUTREACH, or specialized summer camps).Revised: August 2019 ................
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