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Sul Ross State University Ronald E. McNair Post (Sul Ross State University)

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Sul Ross State University
Ronald E. McNair Post Baccalaureate Achievement Program
Participant Application
Please Print or Type
Social Security #: ____________________________ A#: ________________________
Name: __________________________________________________________________
Last First Middle
Local Address: __________________________________________________________
Permanent Address: _____________________________________________________
Cell Phone: ______________________ Alternate Phone: ______________________
Preferred Email: ________________________________ DOB: ____________________
Emergency Contact: _______________________________ Relationship: ___________________
Emergency Contact Phone: ________________ Marital Status:________________
Mark A
LL statements that best describe your first-generation college student status:
□ Neither of my natural or adoptive parent(s) received a four-year college degree.
□ My parents do not live together, and the parent with whom I live(d) with and/or receive(d)
financial support from does not have a bachelor’s degree.
□ Prior to the age of 18, I did not live with or receive support from a natural or adoptive parent.
□ None of these statements apply.
List all financial aid you are currently receiving: (grants, scholarships, loans, etc.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Citizenship
Ethnicity
Gender
□ U.S. Citizen
□ Permanent Resident
Resident Alien
#
______________________
□ African American/Black
□ American Indian/Alaskan Native
□ Asian
□ Pacific Islander
□ Hispanic/Latino
□ White
(other than Hispanic)
□
Other
_________________________
□ Female
□ Male
SR
SU
Student Status
□ Full-time
□ Part-time
Past TRIO Participation: YES or NO
(mark all that apply) □ SSS □ UB □ TS □ Other _____________
Veteran: served more than 180 days, not dishonorably discharged □ YES □ NO
Academic Information:
D
id you attend community college prior to enrolling at Sul Ross? □ YES □ NO
M
ajor __________________________________ Minor _________________________________
Major Advisor ___________________________________________________________________
Current Class Standing: □ Sophomore □ Junior □ Senior
Cumulative: Credit Hours______________ Grade Point Average____________
If your GPA is not at least 3.0, please provide:
Major: Credit Hours______________ Grade Point Average____________
List academic distinctions, leadership activities and/or honorary achievements:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Are you interested in applying to graduate school? □ YES □ NO
I
f yes, in what discipline? ___________________________________________________
I want to receive a:
□ Dr. of Philosophy-PhD □ Dr. of Education-Ed
D □ D
r. of Medicine-MD
□ Doctor of Veterinary Medicine-DVM □ Dr. of Jurisprudence (Law Degree)
□ Other Doctorate___________________________
List the graduate schools you are interested in attending:
_____________________________________________________________________________
Institution City State
_
____________________________________________________________________________________________
Institution City State
_____________________________________________________________________________
Institution City State
_
____________________________________________________________________________________________
Institution City State
_
____________________________________________________________________________________________
Institution City State
M
cNair Research Preference:
I
dentify your preference for a research project: _____________________________________
______________________________________________________________________________
M
entor preference: (1) __________________________ (2) _____________________________
Sul Ross State University
Ronald E. McNair Post Baccalaureate Achievement Program
Needs Survey
Name: ___________________________________________ Date:_______________
Graduate School Planning
M
ark your level of agreement with each of the following statements, based on the following scale:
1=
strongly disagree 2=disagree 3=neutral 4=agree 5=strongly agree
1. I
am knowledgeable about graduate school admission requirements.
□
1
□
2
□
3
□
4
□ 5
2. I am familiar with research methodology and its applications.
□ 1 □ 2 □ 3 □ 4 □ 5
3. I
am familiar with teaching careers at the college level.
□
1
□
2
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3
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4
□ 5
4. I
have written research reports and made presentations at conferences/symposiums.
□
1
□
2
□
3
□
4
□ 5
5. I
am familiar with the steps of writing for publication.
□
1
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2
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3
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4
□ 5
6. I
am knowledgeable of financial aid resources to pay for graduate school.
□
1
□
2
□
3
□
4
□ 5
7. I
am aware of the steps to obtain a doctoral degree (PhD, EdD, etc.).
□
1
□
2
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3
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4
□ 5
8. I
am familiar with “networking” and “mentoring” and its impact on professional success.
□
1
□
2
□
3
□
4
□ 5
9. I
am aware of doctoral study tenets and how to manage tasks and reach my goals.
□
1
□
2
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3
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4
□ 5
I
0. I am aware of the GRE, its contents, and test preparation resources.
□
1
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2
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3
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4
□ 5
11. I am comfortable with writing personal statements, curriculum vitae, and resumes.
□
1
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2
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3
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4
□ 5
12. I
am familiar with how to apply for graduate assistantships.
□
1
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2
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3
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4
□ 5
13. I
am familiar with strategies in developing critical thinking skills.
□
1
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2
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3
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4
□ 5
Specific Skill Development
Ma
rk the following skill(s) with which you feel least comfortable:
□ Computer Skills
□ Li
brary Research
□ Time Management
□ Test Taking
□ Research (hands-on)
□ Research Paper Development
□ Statistical Analysis
□ Presentation Skills
P
ersonal/Social Development
Li
sted below are a number of areas of your life that may influence your studies and your progress
toward obtaining your degree(s). Please mark the item(s) for which you may want to discuss:
K
ey Areas of Need
□ Housing
□ Transportation
□ Employment
□ Financial Worries
□ Budgeting Skills
Personal Relationships
□ Parents
□ Spous
e
□ Significant Other
□ Sibling(s)
□ Friends
□ Roommate
Campus Relationships
□ Student and/or Peer
□ Faculty Research Mentor
□ Professor/Instructor
□ Staff Member
Oth
er: _____________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Sul Ross State University
Ronald E. McNair Post Baccalaureate Achievement Program
Signature Release Form/Certification
N
ame_______________________________ ID#__________________
(Please type or print)
T
his release form enables the SRSU McNair Program to obtain the following information for the
purpose of determining program eligibility, developing educational plans, and collecting program
statistics:
• A
dmission and enrollment documents
• Grade reports and transcripts
• Financial aid reports and information regarding taxable income, awards received,
and
unm
et need
• U.S. Residency status
• Current personal information (address, phone number, e-mail address)
• Past TRIO participation
A
spects of this information and the nature of your participation in the McNair Program may be
shared with the U.S. Department of Education and SRSU personnel in accordance with federal
regulations and SRSU policy.
My signature below indicates that I hereby authorize the release of my
academic, personal, and financial records to the McNair Post
Baccalaureate Achievement Program at Sul Ross State University for
the purpose of serving my needs and meetings its federal regulations. I
also hereby attest that, to the best of my knowledge, the information
given in this application is true, complete, and accurate.
S
ignature_____________________________________ Date_________
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Sul Ross State University
Ronald E. McNair Post Baccalaureate Achievement Program
Income Verification
Please provide the following financial information from your parent’s/your most
recent tax return:
S
tudent’s Name: _____________________________________________________
Filing year: ________
Adjusted Gross Income: $_____________________
Number in Household: ____
Filing Status (select one): □ Single □ Married-Filing Jointly □ Married-Filing Separately
□ H
ead of Household □ Qualified Widower
T
axable Income: $_____________________
I hereby certify that the above information is true and accurate to the best of my
knowledge.
____________________________________ ____________________
Parent Signature Date
******************************************************************
Student signature only needed if considered independent in accordance
with the financial aid office
____________________________________ ____________________
Independent Student’s Signature Date
A
lternative to this form – you may submit a copy of yours and/or your parents most recent
signed Federal Income Tax Return form (example: 1040, 1040A, 1040EZ, etc.)
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signature
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Sul Ross State University
Ronald E. McNair Post Baccalaureate Achievement Program
Recommendation Form
Return to: Box C-63 Alpine, TX 79832, or mcnair@sulross.edu
S
tudent Applicant – Please complete the following information.
(Type or print legibly)
______
________________________________________________________________________
Last Name First Name MI
O
ptional: I hereby waive my right to have access to this recommendation as so indicated by my
signature below. I understand that this waiver will not affect my admission or my ability to receive
any services provided by the McNair Program.
______________________________________________________________________________
Signature Date
The following section is to be completed by a faculty member.
T
his is my evaluation of: __________________________________. I have known this applicant
for _______years in this capacity: ___________________________________________________.
Please evaluate the following qualities of the applicant by circling the appropriate responses.
Promise as a graduate student
superior
average
below average
unable to judge
Perseverance
superior
average
below average
unable to judge
Dependability
superior
average
below average
unable to judge
Maturity
superior
average
below average
unable to judge
Oral expression
superior
average
below average
unable to judge
Written expression
superior
average
below average
unable to judge
Ability to work independently
superior
average
below average
unable to judge
Potential to plan/conduct research
superior
average
below average
unable to judge
Initiative
superior
average
below average
unable to judge
Knowledge and intellectual ability
superior
average
below average
unable to judge
Remarks:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
N
ame (printed) __________________________________ Title ___________________________
E-Mail _________________________________________ Phone _________________________
S
ignature _______________________________________ Date __________________________
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signature
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signature
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Sul Ross State University
Ronald E. McNair Post Baccalaureate Achievement Program
Recommendation Form
Return to: Box C-63 Alpine, TX 79832, or mcnair@sulross.edu
S
tudent Applicant – Please complete the following information.
(Type or print legibly)
______________________________________________________________________________
Last Name First Name MI
O
ptional: I hereby waive my right to have access to this recommendation as so indicated by my
signature below. I understand that this waiver will not affect my admission or my ability to receive
any services provided by the McNair Program.
______________________________________________________________________________
Signature Date
The following section is to be completed by a faculty member.
T
his is my evaluation of: __________________________________. I have known this applicant
for ______ years in this capacity: ___________________________________________________.
Please evaluate the following qualities of the applicant by circling the appropriate responses.
Promise as a graduate student
superior
average
below average
unable to judge
Perseverance
superior
average
below average
unable to judge
Dependability
superior
average
below average
unable to judge
Maturity
superior
average
below average
unable to judge
Oral expression
superior
average
below average
unable to judge
Written expression
superior
average
below average
unable to judge
Ability to work independently
superior
average
below average
unable to judge
Potential to plan/conduct research
superior
average
below average
unable to judge
Initiative
superior
average
below average
unable to judge
Knowledge and intellectual ability
superior
average
below average
unable to judge
Remarks:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
N
ame (printed) __________________________________ Title ___________________________
E-Mail _________________________________________ Phone _________________________
S
ignature _______________________________________ Date __________________________
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signature
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Sul Ross State University
Ronald E. McNair Post Baccalaureate Achievement Program
Statement of Purpose and Academic Documents
Please submit a personal statement to the McNair Program office (BAB 319) or via email
(mcnair@sulross.edu
).
• Write a personal statement describing your experiences as an undergraduate student and
y
our goals moving forward to graduation, graduate school and potentially a doctoral
program. What potential barriers do you think you may face along the way? And how
do
y
ou think the McNair Program will help you achieve your educational and career goals
?
o M
inimum one page, double spaced statement
Please provide the following academic documents:
• Official signed degree plan or signed Degree Works degree plan
• Academic transcript (unofficial from Self-Service Banner/Lobo Online is accepted)
Sul Ross State University
Ronald E. McNair Post Baccalaureate Achievement Program
Application Packet Checklist
___
__ Participant Application
_____ Needs Survey
_____ Release of Information
_____ Income Verification
_____ Recommendation 1
_____ Recommendation 2
_____ Official Signed Degree (Works) Plan
_____ Academic Transcript
_____ Statement of Purpose
Thank you for submitting your application.
Kathleen Rivers
Director, Mc
Nair Scholars Program
mcnair@sulross.edu
432.837.8019 (phone)
432.837.8620 (fax)
BAB 319
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Completed 27 August 2020

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