A. Please check applicable semester(s) or session(s) and select the year.
Fall  20 00 01 02 03 04 05 06 07 08 09 n/a       Spring  20 00 01 02 03 04 05 06 07 08 09 n/a     Summer 20 01 02 03 04 05 06 07 08 09 n/a   

B. First Name:  Middle Name:
     Last Name:    

C. Home Address:
     City: State: Zip Code:

D. Choose the category for which you are applying: Intern or full-time student teacher [category 3] Enrolled in program at other than one of the three campuses [category 4] Graduate student enrolled for thesis or dissertation work only [category 5] Special Part-time student [category 6] Faculty member [category 7] Student Cooperative staff member or spouse [category 7] University staff member [category 8] Student enrolled in short-term course work (ex. workshop) [category 9] Commuter student who travels more than 50 miles one way [category 10]

If you selected [category 9], such as a workshop, please complete:  Course Name
Course # Beginning Date Ending Date 
Instructor Name

If you selected [category 4,5,6,7,8, or 10] please provide information pertaining to your situation: