University of Massachusetts School of Public Health



Department of Biostatistics & Epidemiology

Graduate Assistantship Application Form

Complete application and return to Arnold House, Room 415 or email to dosowski@schoolph.umass.edu

Date: ____________________

Name: _______________________________________ Phone: ________________________

Email address:________________________________

Area of Concentration: (circle one) Bio Epi Other: _______________

Degree Program: (circle one) PhD MS MPH Other Non-Degree

Semester first Enrolled: Fall or Spring _________ (year)

Area(s) of Special Interest (if any):

Specific job(s) you are applying (from the job listing):

1st Choice: ___________________________________________________________________

2nd Choice: ___________________________________________________________________

3rd Choice: ___________________________________________________________________

4th Choice: ___________________________________________________________________

Do you wish to be considered for positions in addition to the ones you have indicated? Yes No

Department of Biostatistics & Epidemiology

Graduate Assistantship Application Form (continued)

List any previous relevant work experience (including previous RA/TA work):

List any special skills / experience (e.g. data entry, interviewing, data management or analysis, library research, scientific writing, teaching, R, SAS or other statistical analysis program, etc.):

Do you have a car available for travel if required? Yes No

Would you be willing to travel if required? Yes No

Do you have any other sources of funding for this semester?

Yes (specify) _______________________ No

Are you interested in doing unpaid work on any research projects for the work experience?

Yes No

List up to 2 people you have worked with in the US who could be contacted to give you a reference

______________________________________________________________________________

Name, location, and phone #

______________________________________________________________________________

Name, location, and phone #

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