Application for Admission

for
Graduate Studies in Chemistry and Biochemistry
at
Montana State University
You may wish to read these

before you begin work on this form.

Read the instructions page first before starting work on your application.

Please Note: No error checking is performed on the data you enter into this form. Please double-check all fields for completeness and correct entries before attempting to submit your application.

Name
Last: First: Full middle:
Previous Name(s):
Semester and Year you expect to enroll

Degree Program Desired:
Chemistry Area of Interest:  
I am applying for an assistantship:


Mailing Address
Street and number: County:
City: State/Province: Zip Code:
Country:
Telephone at above address:
E-mail:

Permanent Address (if different from above)
Street and number: County:
City: State: Zip Code:
Country:
Telephone at above address:

Education
List ALL colleges and universities you have attended, beginning with the most recent.
Name of Institution City and State/Prov. Dates of Attendance Number of Credits Degree Received Date Received

Grade Point Averages
Enter your GPA's in the spaces below. Use the GPA's reported on your college transcript(s).
Cumulative Undergraduate GPA Compute your GPA for all studies leading to your first Bachelor's degree.
Last Two Years' Undergraduate GPA Compute your GPA for your last 60 semester hours or 90 quarter hours of undergraduate study.
Chemistry Undergraduate GPA Compute your GPA for all undergraduate chemistry classes that you have taken.
Graduate GPA Compute your GPA for any coursework undertaken after your first Bachelor's degree.

GRE Scores
Verbal GRE Score:
Quantitative GRE Score:
Analytical GRE Score:
Chemistry GRE Score (optional):

Essay Please state your educational objectives and explain why you wish to enroll at Montana State University. You may also use your essay to state your qualifications and to explain your current and/or past research experiences.

How did you hear about MSU-Bozeman?

Which (if any) MSU-Bozeman Chemistry and/or Biochemistry faculty have you contacted regarding graduate studies at MSU-Bozeman?

References
Please give names, titles, and full addresses of three persons who will complete your letters of recommendation. Other listed fields may be filled in at your option.
  Reference 1 Reference 2 Reference 3
Required Information
Name


Address


City, State, Zip


Title


Optional Information
Telephone


E-mail Address


Employer


Relationship


Do you waive your right to review this recommendation?

Citizenship
Are you a citizen of the United States?
If "No", of which country are you a citizen?
Have you previously taken extended studies courses from this university?

Residency Information
Are you claiming Montana residency?
If "No", in which state do you declare resident status?
    (Please proceed to Section C)
If "Yes" and your parent(s) claim you as a federal income tax exemption, complete Sections A and C.
If "Yes" and your parent(s) do NOT claim you as a federal income tax exemption, complete Sections B and C.
Section A
Complete this section if your parent(s) claim you as a tax exemption

 When did your parent(s) Montana residency begin? (month/year)

Where and when did they last file a state income tax return?
State:
 Date (month/year):
Where and when did they last vote?
State:
 Date (year):
What is their employment status?
Occupation:
Start date of employment:
Employer:
Section B
Complete this section if your parent(s) do not claim you as a tax exemption
 Date your permanent residency began in Montana (month, day, and year)
Reason for moving to Montana (e.g., to attend school, seek employment, accept employment, etc.)
Where and when did you last file your state income tax return?
State:
 Date (month/year):
Did you file as a full-year or part-year resident?
Have you been absent from Montana more than 30 continuous days during the last 12 months?
If "Yes", please explain reason for absence:
Are you a registered voter?
If "Yes", give date and state of registration:
Date (month/year):
 State:
If you drive, complete the following information concerning your driver's license:
State in which drivers license was issued?
Month, day, and year issued?
Is your current license a renewal?
If you own a motor vehicle, complete the following information:
State in which the vehicle is currently registered:
Month, day, and year of vehicle registration:
Is the above registration a renewal?
If you are married, please complete the following information:
Spouse's Name:
Spouse's Address: (e.g. "same")
What is your spouse's employment status?
Start date of spouse's employment:
Spouse's Employer:
For the two years prior to the desired term of enrollment at MSU, will you have been registered for a total of seven or more credits during a semester/quarter at any post-secondary institution (i.e., beyond high school in Montana)?
If "yes", specify school name(s) and date(s) of attendance:
Section C
Employment History 		Describe your employment history for the last three years, beginning with your most recent employment.
Employer 1
 Address (city and state)
Job Title
Dates of Employment
Employer 2
 Address (city and state)
Job Title
Dates of Employment
Employer 3
 Address (city and state)
Job Title
Dates of Employment
Employer 4
 Address (city and state)
Job Title
Dates of Employment
Employer 5
 Address (city and state)
Job Title
Dates of Employment
Employer 6
 Address (city and state)
Job Title
Dates of Employment

Social Security Number*
* We ask you to voluntarily provide your social security number, which permits the school to distinguish between individuals with the same or similar names. You will not be penalized should you decline to provide this number.

Birthdate** (MM-DD-YYYY)     Gender**
** Required for statistical purposes only.

Ethnicity**
** Federal regulations necessitate the collection of data on ethnic backgrounds of students. This information will not be used as a basis for admission.

Forensic Qualifications
Have you ever been subject to discipline, suspension or probation at any institution of post-secondary education for reasons not related to academic performance?
Have you ever been convicted of a criminal offense involving physical injury to persons or property or otherwise institutionalized for conduct causing physical injury to persons or property?

For International Students Only
TOEFL score: **
TSE score:
** A TOEFL score is required of all international students whose native language is not English. For international students on Teaching Assistantships, a TOEFL score of 580 and a TSE or Speak score of 50 are required. If you are providing your own funds or have a sponsor, then the TSE is not required.
Financial Certification (Please check the appropriate box.)
I am providing my own funds in the amount of $22,000.
I will provide partial funds in the amount of $ .
My sponsor (personal or departmental) is providing the balance of the total funds in the amount of $ .
I do not have my own funds. Full funds of $22,000 are being made available to me by my sponsor.
I do not have my own funds. Full funds of $22,000 are being made available to me by the department to which I am applying.
Sponsor Information (if not MSU-Bozeman)
Name:
Address:
City: State/Province/Region:
Postal Code Country:
Please supply documentation/proof of your funding source, including your relationship to your sponsor.
Please consult the department for further information on supplying this documentation.


Certification of Application (read the following carefully and then check the box below.)
I hereby certify that to the best of my knowledge the foregoing information is true and complete without evasion or misrepresentation. I understand that if it is later found otherwise, it is sufficient cause for rejection or dismissal. If my application for admission is approved, I agree to abide by the rules and regulations, both academic and non-academic, of Montana State University, its colleges, schools, departments and institutes, including but not limited to those rules and regulations stated in both the undergraduate and graduate catalogs. I further acknowledge that, if admitted to the College of Graduate Studies, I may be dropped therefrom if I fail to abide by these rules and regulations and that my registration at Montana State University may be subject to cancellation. (check this box to complete your certification of this application)
Date of Certification:



NOTE: This application form will allow you to submit incomplete applications. Please check and re-check your work before submitting your application.

If you have finished entering data into this form, press the "submit" button below. WARNING: pressing the "clear" button will cause you to loose all prior entries in the above form fields.


© Montana State University 2005