This application is to be filed with the Department in which you are requesting the scholarship.
Mr.____ Ms.____
Name_____________________________________
Correspondence address March to May:
__________________________________________
__________________________________________
UNI ID#__________________________________
Social Security #____________________________
Department________________________________
Major____________________________________
Degree sought______________________________
Telephone_________________________________
Correspondence address May to August:
__________________________________________
__________________________________________
Telephone__________________________________
For which semesters) is this application made:
(Must be full-time graduate student to be eligible)
Beginning date of program____________________
Target completion date_______________________
Graduate hours completed____________________
Graduate GPA______________________________
Undergraduate GPA_________________________
____Fall ______(Year, e.g., 2000)
____Spring ______(Year, e.g., 2010)
Degree received Year College/University
___________________________ __________ ________________________________________________
___________________________ __________ ________________________________________________
List scholastic honors received, including membership in honor societies. Indicate important extra-curricular activities. _________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Academic experiences demonstrating outstanding scholarship ________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List at least two persons who are familiar with your scholastic work and whom you have requested to write letters in support of this application. (To be sent to Department Head.)
_________________________________________________________________________________________
With which University of Northern Iowa faculty members, if any, are you well acquainted?
_________________________________________________________________________________________
_________________________________________________________________________________________
Other support for time period covered by this application:
UNI Graduate Assistantship
Fellowships – Identify: ____________________________________
Applied
________
________
Received
________
________
_____________________________________
Other Scholarships – Identify: ______________________________
_______________________________
________ ________
________ ________
________ ________
Signature of applicant______________________________________________ Date____________________
UNI requests this information for the purpose of considering you for a Tuition Scholarship. No persons outside the university are routinely provided this information. Release of any information is governed by Board of Regents rules and applicable state and federal statutes. Responses to all items are required.
If you fail to provide the required information, the University may not consider your application .
8/98

This application is to be filed with the Department in which you are requesting the assistantship.
Mr.____ Ms.____
Name_____________________________________
Correspondence address March to May:
__________________________________________
__________________________________________
UNI ID#__________________________________
Social Security #____________________________
Department________________________________
Major____________________________________
Degree sought______________________________
Telephone_________________________________
Correspondence address May to August:
__________________________________________
__________________________________________
Telephone__________________________________
For which semesters) is this application made:
(Must be full-time graduate student to be eligible)
Beginning date of program____________________
Target completion date_______________________
Graduate hours completed____________________
Graduate GPA______________________________
Undergraduate GPA_________________________
____Fall ____(Year, e.g., 2000)
____Spring ____(Year, e.g., 2010)
Degree received Year College/University
___________________________ __________ ________________________________________________
___________________________ __________ ________________________________________________
List scholastic honors received, including membership in honor societies. Indicate important extra-curricular activities. _________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
List at least two persons who are familiar with your scholastic work and whom you have requested to write letters in support of this application. (To be sent to Department Head.)
_________________________________________________________________________________________
With which University of Northern Iowa faculty members, if any, are you well acquainted?
_________________________________________________________________________________________
_________________________________________________________________________________________
List your teaching experience, if any, indicating location, subjects taught, and dates of employment in each position.___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you now hold a teaching certificate? Yes____ No____ If so, name of certificate and state in which issued:____________________________________________________________________________________
Do you plan to attend continuously until the degree is earned? Yes____ No____
Signature of applicant______________________________________________ Date____________________
UNI requests this information for the purpose of considering you for a Graduate Assistantship. No persons outside the university are routinely provided this information. Release of any information is governed by Board of Regents rules and applicable state and federal statutes. Responses to all items are required.
If you fail to provide the required information, the University may not consider your application .
8/98

CLINICAL TRAINING AND EXPERIENCE
Request Admission for:
Fall ___ Spring ____ ____________
Check one Year
Current Date: _________________
NAME:__________________________________________________________________________________
Last First Middle
ASHA Approved Hours (Supervised by an individual with Certificate of Clinical Competence [CCC] in the appropriate area). List number of Completed and Projected Clinical Hours (by end of undergraduate program) below.
Clinical Assessment/Diagnostic and Intervention Clock Hours
Treatment/Therapy _________ _________
Completed Projected
Child Speech/Language Hours
Assessment/Diagnostic _________
Completed
_________
Projected
Treatment/Therapy _________ _________
Completed Projected
Audiology/Hearing Hours
Adult Speech/Language Hours
Assessment/Diagnostic _________
Completed
Hearing Assessment
Aural Rehabilitation Treatment
_________ _________
Completed Projected
_________
Completed
_________
Projected
_________
Projected
Clinical Observation
Observation-only Hours _________
Completed by End of B.A./B.S.
Application Deadline: January 20 for Fall Admission and September 15 for Spring Admission
Department of Communication Sciences and Disorders
University of Northern Iowa
230 Communication Arts Center
Cedar Falls, IA 50614-0356
319.273.2496
gradappl 9/3/2009