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Department of Urban and Regional Planning
SUPPLEMENTARY QUESTIONNAIRE
FOR Ph.D. APPLICANTS
APPLICATION DEADLINES: Fall
Term: January 15 Spring Term: July 1
For which term, ___ AUGUST, 20___,
FALL TERM
do you seek admission: ___ JANUARY, 20___, SPRING TERM
Please type or
print clearly. Return this questionnaire
directly to Admissions, Department of
Urban and Regional Planning,
is required and
must be filed with the Office of Admissions.
1. NAME:________________________________________________________
2. ___________________________
Family Given Social Security No.(
3. E-MAIL ADDRESS:
____________________________________________
4. PERMANENT HOME
ADDRESS:
_______________________________________________________________________________________________
Street and
Number City State Postal Code Country
5. PRESENT ADDRESS
(if different):
_______________________________________________________________________________________________
Street and
Number City State Postal Code Country
6. TELEPHONE NUMBER:
(home)_____________________________(business):____________________________
7.
CITIZENSHIP:____________________________ 8. DATE OF BIRTH:_______/__________/________________
Month
Day Year
9. GRADUATE RECORD
EXAMINATION: __________/____________/___________/__________/____________
Date Score: Verbal Quantitative Analytical Total
10. TEST OF ENGLISH AS
A FOREIGN LANGUAGE (Int'l applicants only): _____________/__________________
Date Score
Institution Location First
Enrolled Degree Major Date
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
12. UNDERGRADUATE UPPER DIVISION GRADE POINT
AVERAGE:_____________
(average for junior and senior
years--indicate scale if A equals other than 4.0)
13. GRADUATE GRADE POINT AVERAGE (if
applicable):_________________
(indicate scale if A equals other than
4.0)
14. SCHOLASTIC DISTINCTIONS ACHIEVED:
15. EXTRA-CURRICULAR ACTIVITIES:
16. EMPLOYMENT (List professional, military, and relevant
volunteer work you have had in the last five years):
Name & Type
of Dates of Full-Time/ Volunteer
Firm/Agency Employment Part-Time or
Paid Duties
17.
List
any computer software for which you have significant proficiency and the level of proficiency
attained.
Level
of Proficiency
Software Elementary Intermediate Advanced
18. MEMBERSHIP IN LEARNED SOCIETIES OR PROFESSIONAL
ORGANIZATIONS:
18.
STATEMENT.
Please attach a typewritten statement in
which you describe your career goals, the intended focus of
your doctoral studies,
and the manner in which you see your studies as preparing you to satisfy your
goals. Be as specific
as possible.
Include any auto-biographical information you see as pertinent to demonstrating
your abilities to complete
your studies or
satisfy your goals.
20. SIGNATURE:__________________________________ 21.
DATE:_____________________________________
Month Day Year
file=PHDsuppl.app(admsdsk) UPDATED:
10/20/04