Research Experiences for Undergraduates in Assistive Technologies for People
with Disabilities
 Application Form - CSE@UTA - Summer 2018
 A. Personal Information (items marked with * are required):
 1. Name*: ______________________________ 
 2. Social Security No.*: _______________________
 3. Date of Birth*: ________________________ 
 4. Citizenship* (check one): U.S. Citizen____ Permanent Resident____ Other____
 5. Demographic Information: 
    a) Gender: Female____ Male____ 
    b) Ethnicity/Race: Hispanic / Latino____ American Indian / Alaskan Native____ 
      Asian____ Black / African American____  Native Hawaiian / Pacific Islander____ White____
 6. Home Address (include E-mail, if any)*: 
 ___________________________________________________________________________________________________
 ___________________________________________________________________________________________________
 ___________________________________________________________________________________________________
 7. School Name and Address (include E-mail, if any)*:
 ___________________________________________________________________________________________________
 ___________________________________________________________________________________________________
 ___________________________________________________________________________________________________
 8. Telephone numbers*: 
   Home: _________________________ School: _________________________
9. Names of Refereneces*:
 ___________________________________________________________________________________________________
 ___________________________________________________________________________________________________
 ___________________________________________________________________________________________________
B. Academic Background (items marked with * are required):
1. Current cumulative GPA*: _______________ 
2. Major*: ________________________________________
3. Number of credit hours completed*: _______ 
4. Classification in Fall 2014 semester* (check one): Sophomore____ Junior____ Senior_____
5. Academic and Extra-Curricular Accomplishments (including awards, prizes, scholarships):
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
6. Briefly explain any team work or group project you have been involved with:
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
7. Computer Systems, Programming Languages, and Operating Systems Experience:
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
 ____________________________________________________________________________________________
C. Personal Statement:
 Describe in one page or less your research interests and how you came to be interested in those areas,  your previous research experience and how this program might prepare you for the future, and  your reasons for wanting to participate in this research opportunity. 
 Also, if you believe that your academic record does not accurately reflect your potential, please explain briefly why.





Page 1 from 3