UniversityLink Medical Science Program

Online Application for 2009

Home | Eligibility & Selection Criteria | Application Instructions

Please read all the instructions before completing this application. ALL fields are required except where marked "optional".

1. Student Information
Full Legal Name:	Last	First	Middle Initial
Sex:	Female Male
U.S. Social Security Number:	- -
Date of Birth:
Mailing Address:	Street Address
	City	State:	Zip:
Permanent Address: (if different from above)	Street Address
	City	State:	Zip:
Phone:
Cell Phone:
Email Address:
Alt Email Address:
Intended University Major:
To which University will you be transferring?:
Ethnicity:
Race: (check all that apply)	American Indian or Alaska Native Asian Please specify Asian: Black or African American Native Hawaiian or other Pacific Islander White Other Please specify Other:
Residency:	Are you a California Resident? Are you a US Citizen or Permananet Resident?

Please list up to four people who DO NOT live with you, but who usually know hot to reach you (like a grown brother, sister, aunt, uncle or good friend). Try to list two relatives. They can live anywhere in the U.S.
	First/Last Name	Relationship	Phone Number
1.
2.
3.
4.

2. Educational History
Community College Attendance:
Dates of Attendance:	Begin:	Expected Transfer Date:
Qualifying Program:	* You must be in UniversityLink or TAG to apply
Current GPA:
Semester Units:	Completed	In Progress
High School Attended:	Name	Diploma/Certificate & Year
How far are you expecting to go with your education?	Trade School Associates Degree Bachelor's Degree Master's Degree Doctorate
List four of the career track options you are considering:	Do so in rank order, ie.e #1 = the career you would most realistically see yourself pursuing. 1. 2. 3. 4.

3. Family Information
	Parents' Gross Annual Income: (include income earned by all parents and step-parents that contribute to the support of your household)	Student's Gross Annual Income: (do not count as income any financial aid you received)	Family Size (include yourself, parents and other dependents)
2006
2007
	Is this a single-parent family? Yes No
	Have you ever qualifed for free or reduced lunch in school? Yes No
Father	Highest Level of Formal Education	Occupation, if living:
Mother	Highest Level of Formal Education	Occupation, if living:

4. Extracurricular Information
Extracurricular Activities
Activity	Description of Activity (note any leadership positions)	Year(s) Involved	Hours per Week	Weeks per Year





Volunteer Work and Community Service (unpaid)
Activity	Description of Activity (note any leadership positions)	Year(s) Involved	Hours per Week	Weeks per Year





Special Program Participation (indicate participation in programs such as EOPS, MESA and Puente)
Activity	Description of Activity (note any leadership positions)	Year(s) Involved	Hours per Week	Weeks per Year

5. Work History
Please list and describe briefly any paid employment in the past four years.
Position	Responsibilities	Begin MM/YY	End MM/YY	Hours per Week

Please list any courses you anticipate taking during summer 2009 (include campus you plan to attend and course dates).

The essay is an essential part of your application. The committee will use this statement to learn more about you as an individual, including your aspirations and goals. Think of this statement as an opportunity to introduce yourself to the selection committee and to tell us about events or circumstances that are not evident from a review of the rest of your application.

Your essay should be approximately one page (approximately 550-650 words) and should fit in the space below without having to scroll.

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