University of Northern Iowa
McNair Scholars Program Application
Please complete and return to:
McNair Scholars Program
007 Innovative Teaching and Technology Center
mcnair@uni.edu
Date:
General Information
Name:
Last
First
Middle
Campus Address:
City:
State:
Zip:
State:
Zip:
Permanent Address:
City:
Cell Phone:
Email address:
Local Phone:
Work Phone:
Student ID:
Date of Birth:
Gender:
M
F
Citizenship:
U. S.
Resident
Other
Alaskan Native
American Indian
Asian
Black (non-Hispanic)
Hispanic/Latino
Native American Pacific Islander
Native Hawaiian
White
Do not wish to respond
Ethnic Heritage: (check all that apply)
Other: ________________________
Academic Information
Did you attend a two-year or community college following a high school diploma:
Yes
Previously Attended College(s):
Classification:
Freshman
Sophomore
Junior
Number of Credits Earned:
Expected Graduation Date:
Current UNI GPA:
Transfer Credits GPA:
Major(s):
Minor(s):
Senior
/
No
List any honors, awards, or special recognition received while in college:
Briefly describe any prior research experience in a university setting or elsewhere:
Do you plan to apply to a Ph.D. program upon completion of your baccalaureate degree?
Yes
No
What is your potential field of interest for graduate study?
Have either of your parents received a bachelor’s degree or higher?
Mother:
Yes
No
Degree:
Father:
Yes
No
Degree:
Financial Information
Dependent students complete Table A (someone else claims you as a dependent on an income tax form).
Independent students complete Table B (you file your own income tax form).
Table A
Table B
What is the size of your parents’ household, including
What is the size of your household, including
yourself?
yourself?
Did your parents file a federal income tax return last
Did you file a federal income tax return last year?
year?
Yes
No
Yes
No
If no, put a “0” on the line below for taxable income.
If no, put a “0” on the line below for taxable income.
If yes, what was their taxable income?
If yes, what was your taxable income?
$
$
PLEASE READ: For purposes of documentation, please attach a photocopy of the appropriate signed federal
income tax form. If you are claiming no income for last year and you are an independent student, please request a
substitute 1040 form from the McNair office.
Additional Requirements
Further Application Documents
With your application, please also include the following documents. These are available at
http://www.uni.edu/web/mcnair/how-apply or at the McNair Scholars Program office:
Tax Return or 1040 Substitute
Authorization for Release of Information
Form I-9
Certification of Eligibility for Federal Assistance in Certain Programs
Emergency Contact Information
Name:
Relationship:
Address:
Phone:
Signature
The University of Northern Iowa McNair Scholars Program requests this information for the purpose of
determining your eligibility. No personal, identifiable information is provided to anyone outside the
McNair Scholars Program, except with your permission. Failing to provide the required information may
prevent you from being admitted to the McNair Scholars Program.
Your signature on this form is your assurance that, to the best of your knowledge, all information
provided is true and accurate at this time.
Signature
Date
The McNair Scholars Program at the University of Northern Iowa is funded by a five-year,
$216,834 grant from the U.S. Department of Education.
McNair Scholars Program ● 007 Innovative Teaching and Technology Center
University of Northern Iowa ● Cedar Falls, IA 50614-0388
On-Campus Mail Code: 0388 ● Phone (319)273-2284 ● Fax (319)273-2982
mcnair@uni.edu ● www.uni.edu/web/mcnair