Department of Health Promotion and Policy
Graduate Assistantship Application Form
To apply for a Graduate Assistantship position, please fill out this application and return it to the Department of
Health Promotion and Policy Main Office, Arnold House, Room 330 (or via Email to
gjseaman@schoolph.umass.edu ). Shortly after review by the faculty, you will be contacted via Email if you have
been awarded a position, or not awarded a position. If you are not awarded a position, your application will be
kept on file for 3 months.
Date: ___________________
Name: _______________________________________
Phone: ________________________
Email address: _________________________________
Area of Concentration (circle one):
CHE HPM Other: _______________
Degree Program: (circle one)
PhD
MS
MPH
Semester first Enrolled:
Fall or Spring
Other
Non-Degree
_________ (year)
Area(s) of Special Interest (if any):
Specific job(s) you are applying (from the job listing):
1st Choice: ___________________________________________________________________
2nd Choice: ___________________________________________________________________
3rd Choice: ___________________________________________________________________
4th Choice: ___________________________________________________________________
Do you wish to be considered for positions in addition to the ones you have indicated? Yes
No
Department of Health Promotion and Policy
Graduate Assistantship Application Form
List any previous relevant work experience (including previous RA/TA/other work):
List any special skills / experience (e.g. data entry, interviewing, data management or analysis,
library research, scientific writing, teaching, etc.):
Do you have a car available for travel if required?
Yes
No
Would you be willing to travel if required?
Yes
No
Do you have any other sources of funding for this semester?
Yes (specify) _______________________
No
Are you interested in doing unpaid work on any research projects for the work experience?
Yes
No
List up to 2 people you have worked with in the US who could be contacted to give you a reference
______________________________________________________________________________
Name, location, and phone #
______________________________________________________________________________
Name, location, and phone #
University of Massachusetts Amherst
EQUAL OPPORTUNITY/AFFIRMATIVE ACTION
INFORMATION REQUEST
Since you have recently applied for a position at the University of Massachusetts Amherst, we would
appreciate your cooperation in providing the information requested on this form. Your participation is
voluntary, and will in no way affect your eligibility for employment. This information is confidential and will
be used to determine the success of the University's affirmative action outreach programs and to comply with
federal and state law.
Please return this form to the University Department conducting the search (see address on enclosed letter).
NAME: ___________________________________________________ DATE: ______________________________________
POSITION APPLIED FOR: _________________________________________ RANK: ______________________________
DEPARTMENT/SCHOOL: _______________________________________________________________________________
Information on this position came to me from the following source: (Name specific newspaper, journal, person, etc.)
________________________________________________________________________________________________________
ETHNIC DATA:
The categories below should not be interpreted as scientific or anthropological in nature. They were developed by the Federal
government to provide for the collection and use of compatible and exchangeable ethnic data by Federal agencies: (CHECK
ONE)
_____ White (a person not of Hispanic origin, having origins in any of the original peoples of Europe, North Africa, or the
Middle East.)
_____ American Indian or Alaska Native (a person having origins in any of the original peoples of North America and who
maintains a cultural identification through tribal affiliation or community recognition.)
_____ Asian or Pacific Islander (a person having origins in any of the original peoples of the Far East, Southeast Asia, the
Indian subcontinent or the Pacific Islands.)
_____ Black/African American (a person not of Hispanic origin, having origins in any of the Black racial groups of Africa.)
_____ Cape Verdean (a person not of Hispanic origin, having origins in any of the peoples of the Cape
Verde Islands.)
_____ Hispanic/Latino (a person of Mexican, Puerto Rican, Cuban, Central American, South American or other Spanish culture
or origin, regardless of race.)
SEX:
FEMALE ________ MALE _________
VETERAN STATUS:
VIETNAM ERA VETERAN? ______ YES _______ NO
OTHER VETERAN? ______ YES _______ NO
See Military Status definitions on the reverse side.
MILITARY STATUS DEFINITIONS
VETERAN OF THE VIETNAM ERA:
A Veteran of the Vietnam era is a person who:
(A) served on active duty for a period of more than 180 days, and was discharged or released therefrom with
other than a dishonorable discharge, if any part of such active duty occurred: (i) in the Republic of Vietnam
between February 28, 1961, and May 7, 1975; or (ii) between August 5, 1964, and May 7, 1975, in all other
cases; or
(B) was discharged or released from active duty for a service connected disability if any part of such active
duty was performed: (i) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (ii)
between August 5, 1964, and May 7, 1975, in all other cases.
OTHER VETERAN:
Any other Veteran who served on active duty during a war or in a campaign or expedition for which a
campaign badge has been authorized.
In compliance with Federal Regulations and the Jeanne Clery Disclosure of Campus Crime Statistics Act, a
copy of the University of Massachusetts Amherst Annual Security Report is available online at
http://www.umass.edu/umpd/pdffiles/ASR.pdf. A hard copy of the report may be obtained by
contacting the UMass Amherst Police Department at (413) 545-2125. This report includes crime statistics for
the previous three years as well as institutional policies concerning campus security.