SEAGEP Fellowship Student Data Form

First Name:
Last Name:
Date of Birth: / /  ( MM / DD / YYYY )
UFID:
Email:
Citizenship:

 United States Citizen
Permanent Resident
Non Resident
*Gender: Male   Female
*Ethnicity: Hispanic/Latino
Not Hispanic/Latino
Unknown
*Race:
(Note: If you checked Hispanic/Latino above then you would check Caucasian; unless another race is applicable)		 Asian (A)
African American (AA)
Caucasian (C)
Native American (NA)
Pacific Islander (PI)
Mixed C or A
Mixed NA, PI or AA
Other/Unknown
Disabled?: Yes   No
School Address:
City:
State/Province:
Zip/Postal Code:
Permanent Address:
City:
State/Province:
Zip/Postal Code:
Phone:  -  -  -   Ext.
Fax:  -  -  -   Ext.
Name of your most recent previous institution:
Dates of Attendance:
Major:
Degree Received: Master of Science
Master of Engineering
PhD
Other:
GRE - Date Taken:
GRE - Score/Percentile - Verbal:
GRE - Score/Percentile - Quatitative:
GRE - Score/Percentile - Analytical:
Name of Graduate Department:
Name of Graduate Committee Chair (if established):
Expected Graduation Date: / /  ( MM / DD / YYYY )
GPA:
Dissertation Title (if known):
How did you find out about the SEAGEP program?:

*This information is requested by the NSF for reporting purposes only