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1).
First Name
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2).
Middle Initial
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3).
Last Name
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4).
Address Line 1
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5).
Address Line 2
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6).
City
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7).
State
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8).
ZIP
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9).
Email Address
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10).
Phone Number 1
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11).
Phone Number 2
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12).
Country
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*13). Marital Status
| Single
Married
Separated
Divorced
Other
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*14). Ethnic Background
| African American/Black
American Indian
Alaska Native
Asian/Pacific Islander
Caucasian/White
Hispanic
Other
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*15). Sex
| Male
Female
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*16). Birth Date (MM/DD/YYYY)
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*17). Age
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*18). Citizenship Status
| U.S. Citizen
Permanent Resident
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19). Social Security # (optional)
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*20). Are you a military veteran?
| Yes
No
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21). Do you receive any of the following?
| Student Financial Aid
AFDC
VA/GI Bill
Soc. Sec./S.S.I
Child Support
Food Stamps
Other
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22). If you receive financial aid, what type are you receiving?
| Grant
Work Study
Loans
Scholarships
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23). If you are receiving scholarships, please list:
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*24). Do your parents claim you as a dependent on their Federal Income Tax Return?
| Yes
No
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*25). Do you file your own Federal Income Tax Return?
| Yes
No
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26). Number of dependents in your household: (include yourself and any others that live in our household)
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*27). Your current emploment status:
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*28). Have you participated in any of the TRIO programs? (If so, please list)
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*29). Do either of your parents have a four year college degree?
| Yes
No
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*30). What is the highest grade level completed by your mother?
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*31). What is the highest grade level completed by your Father?
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32). What is the highest grade level completed by your stepmother? (if none leave blank)
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33). What is the highest grade level completed by your stepfather? (if none leave blank)
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*34). Parents' Marital Status
| Single
Married
Divorced
Separated
Other
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*35). May we use your personal information for statistical and/or follow-up information?
| Yes
No
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*36). University Status
| Freshman
Sophomore
Junior
Senior
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*37). Date of first enrollment at ACU
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*38). Current number of ACU hours accumulated?
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*39). If transferring to ACU, what is the number of hours accumulated from other colleges?
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*40). Your current cumulative GPA
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*41). Major(s) field of study
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*42). Expected Date of Graduation
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*43). Are you presently on academic probation?
| Yes
No
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*44). Your academic advisor and department
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*45). Plans after graduation
| Masters
Doctorate (Ph.D)
Professional School (Medical, Law, etc.)
Full-Time Employment
Other
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46). Do you have a physical or learning disability? (If so, please specify)
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47). The McNair Scholars Program offers many services to students. Please check the areas in which you feel you need assistance
| Preparation for Grad School
Graduate Program Selection
Tutoring
Academic Advising
Study Skill
GRE Preparation
Test-taking Skills
Relationships
Graduate Admissions
Financial Assistance
Personal Counseling
Career Counseling
Research Skills
Stress Management
Mentoring
Interpersonal/Communication Skills
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48). Who referred you to this program?
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*49). I hereby certify that the above information is true and correct to the best of my knowlege. I further authorize the McNair Scholars Program to receive copies of all my academic and financial aid records, including transcripts, grade reports, financial aid eligibility, and any other information pertaining to my enrollment in McNair, and if accepted I also understand that the requirements of research hours, attendance at meetings, seminars and other McNair events, is basis for my continuation in the program. I also understand that I may be removed from the program for failure to comply with the required program rules.
| Yes, I agree
No, I do not accept
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50). Please type your full name to certify that all above information is true.
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