Office of State Grants * 100 Rothschild Place * Ithaca College * Ithaca, NY 14850 * 607-274-1267
Collegiate Science and Technology Entry Program (CSTEP)
Application for Entry – AY 2015/2016
Student Name: ____ __________________ Student Identification Number:____________
Social Security # LAST 4 digits only: _____________________
Sex:
Male
Female
Class Level:
Freshman
Date of birth (00/00/00): _______________________
Sophomore
Junior
Senior
Race/Ethnicity (check all that apply):
African or African American*
Asian/Pacific Islander
Hispanic/Latino
Native American/Alaskan Native
White
Other
*(Includes all individuals of African descent)
Major/Minor/School:
Intended Career Field (check all that apply):
Accounting
Speech/Language Pathology
Athletic Training
Law
Computer Information Systems
Computer Science
Health Professions
Education (Math & Science only)
Mathematics
Psychology
Biology, Chemistry or other Natural Science
Social Work
Medicine
Occupational or Physical Therapy
Audiology
***Are you intending to pursue New York State licensure for any profession? If yes, please list
_______________________________________________________________________________________
Ithaca Address (not applicable for pre-freshmen):
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Ithaca Phone Number: ________________________________________________________________________________
Ithaca College Email Address:
_________________________________________________________________________
NOTE: We will use your Ithaca College Email to Contact You
New York State resident?
Yes
Are you a Permanent Resident Alien?
No
Yes
No
If yes, what is your registration number? :__________________________________________________________________
What is your country of birth? ___________________________________________________________________________
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Parent(s)/Guardian(s) Name: ___________________________________________________________________________
Parent(s)/Guardian(s) Address: __________________________________________________________________________
__________________________________________________________________________________________
Parent’s home phone number: ___________________________________________________________________________
Parent’s daytime telephone number: ______________________________________________________________________
High school attended/city: ______________________________________________________________________________
Were you ever a participant in the STEP program?
Yes
No
Do you participate in any other Ithaca College programs?
Yes
If yes, check all that apply:
MLK Scholars
HEOP
IAP
No
Other _________
I, ___________________ _______________, agree to fully participate in the CSTEP Program at
Ithaca College, if accepted. If I am applying based on my financial eligibility, I agree to provide
the appropriate documentation as requested.
________________________________________
_____________
Participant’s signature
Date
FOR OFFICE USE ONLY:
Eligibility Classification: ____________________________
Accepted
Date____________________
Not accepted
Reason for refusal ________________________________________________________________________________________
CSTEP Director’s Signature _______________________________________________________________________________
REV 8/2015
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