CUIR Undergraduate Research Application Form
deadline September 14, 2012 11:59 p.m.
Do you graduate in December 2012?
No
Yes
Contact Information
Name
first middle last
Address
City
State
-pick one
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Zip
Home Phone
Cell Phone
Email
UWM Information
Student ID Number
Year in School
-pick one-
Freshman
Sophomore
Junior
Senior
Major and/or Minor
If undecided check here
School or College
Choose all of the following areas of research you have an interest in:
Arts and Culture
Community Development
Other
College Access
Environmental Issues
Education
Public Health
if other:
Career Goals
Reasearch experience you have:
Interests you have in community development:
Describe how a research internship program would support or strengthen your academic
work and/or career opportunities:
Do you have experience working with Microsoft Excel?
-pick one-
yes
no
Some projects may require students to travel to off-site locations in the city of Milwaukee
Are you able to travel to different areas in the City of Milwaukee?
-pick one-
yes
no
Work Experience
Employer
Position Held
Time of Employment
Primary Responsibilities
Reason for Leaving
Employer
Position Held
Time of Employment
Primary Responsibilities
Reason for Leaving
Employer
Position Held
Time of Employment
Primary Responsibilities
Reason for Leaving
May we contact the Employers named above?
-pick one-
Yes
No
If no, please explain:
Attach Resume:
PLEASE READ CAREFULLY: I hereby certify that the statements and answers given by me on this application are true and correct. I hereby authorize you to contact references, past or present employers (except as noted above), person, schools, law enforcement agencies and any other source of information which may be relevant to my application. It is understood and agreed that any misrepresentation , false statement or omissions by me in this application will be sufficient reason for rejection of my application or for dismissal at any time during my enrollment with the Community Development Work Study Program, without liability to the University of Wisconsin-Milwaukee. I have read, understand and agree to the above statements.
check this box if you agree to the above
ATTENTION
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