McNair Program Application

Applicant:

First Name

Last Name

Permanent Address:

Number and Street

City

State

Zip Code

Contact Information:

() -

Home Telephone

Employment Telephone

E-mail Address

Date of Birth:

Month

Day

Year

EagleLinks ID Number:

Please provide the names, addresses and telephone numbers of 2 contacts with whom you would keep in touch if you were to relocate. (Example: parents, grandparents, guardian)

Name of 1st Contact

Relationship to Applicant

Address

City

State

Zip Code

() -

Telephone Number

Name of 2nd Contact

Relationship to Applicant

Address

City

State

Zip Code

() -

Telephone Number

Race/Ethnicity:

African American

Asian American

Caucasian American

Hispanic American

Native American

Other

Please specify if other:

Gender:

Female

Male

Nationality:

U.S. Citizen

Permanent U.S. Resident

Other

Please specify if other:

10.

Participation in Special Programs (Please check the programs in which you have participated in the past.)

Talent Search

Educational Opportunity Center

Upward Bound

Student Support Services

11.

Classification:

12.

Major Field of Study:

13.

Field in which Applicant Aspires to Earn Doctoral Degree:

14.

Area of Specialization:

15.

Has your mother or father earned a four-year college degree?

Yes

16.

Were you claimed as a dependent by your parent(s) or guardian(s) during the previous tax year?

Yes

(If your answer is Yes, please skip 17 and 18 and send a copy of last year's Form 1040 or 1040A on which you were claimed as a dependent. If your family did not submit a form 1040 or 1040A, please skip 17 and proceed to 18.)

17.

Were you an independent student during the previous tax year?

Yes

(If your answer is Yes, please skip 18 and send a copy of last year's Form 1040 or 1040A. If you did not submit a form 1040 or 1040A, please proceed to 18.)

18.

TO BE COMPLETED ONLY BY THE HEAD OF THE HOUSEHOLD OR BY AN INDEPENDENT STUDENT.

I hereby certify that in (previous year), my household size was (number) and my taxable income was $.

Signature of Head of Household OR of Independent Student *

Signature

Date

19.

To the best of my knowledge, all of the information presented in this application is complete and accurate. *

Applicant's Signature

Date

* This form requires a signature, and you will have to send us a signed copy before we can complete your enrollment. The applicant and/or the head of household must mail in a signed and dated copy of the form. After you have reviewed the information you entered and submitted this online form, you will have two choices:

Print the form, sign the printed copy and mail it to the address provided. We will begin reviewing the electronically submitted application immediately upon its receipt. You can not be admitted to the program until the signed form is received by us.

If you cannot print the form, we will mail you a printed copy of the information that you send through this online form so you can sign it and return it to us. You must check in the box below for this option.

Mail me a copy of this form to sign.

You can also use the PDF application and mail it to us. This online form was included as a convenience for those who choose to use it.

All applications must include the following documents before the applicant is considered for admission into the Coppin State Universty McNair Program:

the signed application
3 recommendation forms
the appropriate tax form

CONFIDENTIALITY: The information contained in this application shall not be publicly disclosed except as required by law.






Wednesday December 3, 2008