Name: _________________________________________ ID#: __________________________

Home Address:______________________________City/State/ZIP________________________

Local Address: ______________________________City/State/ZIP________________________

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 and letters to Dr. Liszka, Dept. of Computer Science, CAS 227 by March 20, 2009.