OFFICE USE
ONLY:
DATE REC:________ DEPT:_________ PROG:__________________ DATE ACCEPT:________ GPA:_______
COLLEGE OF LIBERAL STUDIES
SCHOOL PSYCHOLOGY
UNIVERSITY OF WISCONSIN—LA CROSSE
GRADUATE ASSISTANTSHIP APPLICATION
DIRECTIONS: Mail completed application to:
Dr. Robert J. Dixon, Director
School Psychology Program – 341 Graff Main Hall
University of Wisconsin – La Crosse
La Crosse, WI 54601
Phone: (608) 785-8441
Fax: (608) 785-8443
email: rdixon@uwlax.edu
DEADLINE: Applications must be received by March 1st.
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Name (Last)
(First)
(Middle)
Date of Birth
Social Security #
Male
Female
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Permanent Address
City
State
Zip
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Local/Temporary Address
City
State
Zip
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Permanent Phone #
(_____)___________________
Local Phone #
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Email address
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State of legal residency
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Graduate GPA
_________________
Undergrad. GPA
_____________________________________
Ethnic Background
__________________________________
Country of Citizenship
________/________/________
Anticipated Date of Graduation
NOTE: A student must be unconditionally admitted to the School Psychology graduate program with a minimum of 3.0
GPA to be eligible for a graduate assistantship.
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Signature of Applicant
Date Submitted
THE UNIVERSITY OF WISCONSIN-LA CROSSE IS AN AFFIRMATIVE ACTION EQUAL OPPORTUNITY EMPLOYER
AND IS IN COMPLIANCE WITH TITLE IX AND SECTION 504
COMPUTER/INSTRUCTIONAL TECHNOLOGY SKILLS:
Word Processing
Statistical Analysis
Database Management
Spreadsheet
Graphics
Electronic Communications
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_____Yes
_____Yes
_____Yes
_____No
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_____Advanced
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_____Advanced
_____Advanced
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_____Intermediate
_____Intermediate
_____Intermediate
_____Intermediate
_____Intermediate
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_____Beginner
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PROFESSIONAL REFERENCES:
List three persons who have agreed to submit up-to-date letters of recommendation regarding your qualifications for
graduate coursework and specific assistantship responsibilities. Letters of recommendation must be mailed to Dr. Robert
Dixon by March 1st (see address on front). It is your responsibility to check with references to be certain they have
forwarded letters to complete your Graduate Assistantship Application file. All letters are due by the stated deadline on
the front page. Letters of recommendation already submitted for admission to the School Psychology Program may be
used for this purpose.
Name
Position
Complete Mailing Address
Work Phone Number
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LIST ALL HIGHER EDUCATION INSTITUTIONS ATTENDED (Begin with most recent):
Institution
State
Major(s)
Minor(s)
Degree(s) Awarded
Dates Attended
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LIST RELATED PROFESSIONAL EXPERIENCES (Paid & Volunteer—Begin with most recent):
Employer
Location
Duties/Roles
Dates of Experience
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