REU UTA EE Dept. Application Form

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NAME

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ADDRESS

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CITY, STATE, ZIP

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PHONE

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EMAIL

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COLLEGE CURRENTLY ATTENDING

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YOUR MAJOR

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CURRENT STANDING

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GPA

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CITIZENSHIP (Only US citizens and Permanent
Residents are eligible for this Program.)

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EXTRACURRICULAR ACTIVITIES

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AWARDS, PRIZES, SCHOLARSHIPS

Please tell us why you would like to participate in
UTA's NSF REU Program.

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Signature of Applicant Date

We request the following information in order to meet federal reporting requirements for all
applicants. Submission of this information is voluntary.

Applicant's Name __________________________________________________________________________

Social Security Number _____________________________________________________________________

Date of Birth ____________________________ Sex: ( ) MALE ( ) FEMALE

Handicapped

( ) YES ( ) NO

( ) Mobility Impaired

( ) Visually Impaired

( ) Other (please specify)

( ) Hearing Impaired

( ) Learning Disability

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If you have any handicap or condition which would require special consideration in your
assignment, please indicate above and describe any accommodation which may be necessary for
you. ____________________________________________________________________________________

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Ethnic Data:

( ) American Indian or Alaskan Native

( ) Asian Pacific Islander

( ) Black (Not of Hispanic origin)

( ) Caucasian (Not of Hispanic Origin)

( ) Hispanic

The University of Texas at Arlington is an Equal Opportunity Employer and actively seeks applications from all qualified persons, regardless of sex, religion, national origin, age, or handicap.

Send your application to :

Dr. Saibun Tjuatja
The University of Texas at Arlington
Department of Electrical Engineering
REU Program
Box 19016
Arlington, TX 76019

Fax # (817) 272 - 2253