DEPARTMENT OF MATHEMATICS, PHYSICS, & COMPUTER SCIENCE
GRADUATE FELLOWSHIP/DOCTORAL FELLOWSHIP APPLICATION
Name:_________________________________________
(last)
(first)
(m.i.)
DATE:_________________
Academic year applying for:__________________
Permanent Address:____________________________________________________________
(street)
____________________________________________________________
(city)
(state)
(country)
(zip code)
Phone Number:__________________________________
Address where you can be reached during the summer:
____________________________________________________________
(street)
____________________________________________________________
(city)
(state)
(country)
(zip code)
Phone Number (s): ______________________________________________________________
Undergraduate Education
College(s)_____________________________________________
Degree: _______________
_____________________________________________
Degree: _______________
Graduate Education
College(s)_____________________________________________
Degree: _______________
_____________________________________________
Degree: _______________
Teaching Experiences: _____________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Graduate Program to which you have applied at Springfield College:______________________
Graduate/Doctoral Fellowship for which you are applying
(If you are applying for a Fellowship in more than one area, please indicate your priority to the right.)
Computer Science
__________
_________Priority
Mathematics
___________
_________Priority
Physics/Physical Science ___________
_________Priority
(over)


List below pertinent courses that you have taken that would support your application for the
fellowship of your choice listed.
Please indicate the grade that you received to the right of each course
Computer Science
Courses
Mathematics
Courses
Physics/Physical Science
Courses
References:
_________ My references are on file at the Graduate Admissions Office, Springfield College
_________ I will ask three people to send references to:
Dr. Peter J. Polito, Chairperson- Phone:413-748-3313; EMAIL: ppolito@spfldcol.edu
Department of Mathematics, Physics, & Computer Science
Springfield College
263 Alden Street
Springfield, MA 01109
Personal Statement to Support Your Application:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________