Name: _________________________________________ ID#: __________________________

Home Address:______________________________City/State/ZIP________________________

Local Address: ______________________________City/State/ZIP________________________

College or School: _______________________________ Major: _________________________

GPA: _______________________ Expected Graduation Date: ___________________________

Field Experience in your Discipline: _________________________________________________

______________________________________________________________________________

Participation in H. S. Science Fairs as an Entrant or Judge: _______________________________

______________________________________________________________________________

Participation in Student Chapters of Technical Societies: _________________________________

______________________________________________________________________________

Other Extra-curricular Activities: ____________________________________________________

______________________________________________________________________________

Career Objectives: _______________________________________________________________

______________________________________________________________________________

Financial Need: _________________________________________________________________

______________________________________________________________________________

Local Phone Number: __________________ Home Phone Number: _______________________

e-mail address: _________________________________________________________________

Signature: _________________________________________ Date: _______________________

Note 1: Attach extra pages to this form if you need more space for any of your answers.

Note 2: Letters of support from the University of Akron faculty can also be attached.

Send completed form to Dr. Kathy Liszka, Dept. of Computer Science, by March 26, 2007.