Stephen F. Austinstateuniversity

STEPHEN F. AUSTINSTATEUNIVERSITY

SCHOOL PSYCHOLOGY PROGRAM

APPLICATION FORM

NAME: ______

LASTFIRST MIDDLE

PRESENT ADDRESS:

______

STREET OR P.O. BOX CITY STATE ZIP CODE

PHONE: ______EMAIL ADDRESS:______

Have you ever used a name different than that above? If so, what name?

______

NAME AND ADDRESS OF PERSON THROUGH WHOM YOU CAN ALWAYS BE CONTACTED:

______

NAMEADDRESSPHONE NUMBER

List the names of the persons who agreed to submit letters of recommendation to SFA.

1) ______2) ______3) ______

ETHNIC BACKGROUND: (check one)

African American

Native American

Caucasian/White

Asian American

Hispanic

Other (please specify)

______

International Candidate

Citizen of: ______

Applicants are requested to indicate their ethnic background and citizenship status. This information is optional, but important to the success of our Affirmative Action program. You may, without prejudice, elect not to supply this information. If you do so elect, please include a statement to that effect.

AREA OF EDUCATIONAL INTEREST

Professor(s) with whom you are most interested in working (Please list only one faculty member within the School Psychology Program; see faculty profiles(:

List up to 6 other courses (along with the grades received in those courses), that you feel are relevant to your planned field of study.

______

RESEARCH EXPERIENCE – Check all that apply and elaborate upon this in your essay.
Psychology / Other Sciences
Research Assistant / Research Assistant
Research paper presentation / Research paper presentation
Research Publication / Research Publication
School Psychology or related area experience
Indicate what school psychology experience you have had, the name of your supervisor, the number of hours per week, and the number of weeks.
Work in mental health setting(s) / Hours/week / ______
______/ No. of months / ______
Location
______/ Course Credit / Yes______No______
Supervisor
Know that you are entering a field of study that leads to a professional license. If you have a history of criminal activity, you may not be allowed to complete required field or clinical experiences on public school campuses and other training sites. You may not be considered eligible for professional state licensure as well.
Please indicate if you are interested in a Graduate Assistant Position. ______
Please indicate Full Time or Part Time Status. ______
On a separate sheet, please provide full length answers to the questions
listed on the application checklist and attach it to your application.
PLEASE RETURN THIS FORM TO:
Crystal L. Evans
Program Administrative Assistant
Department of Human Services
Stephen F. Austin State University
P.O. Box 13019, SFA Station
Nacogdoches, TX 75962-3019