Ronald E. McNair Post-Baccalaureate
Achievement Program
Application for Admission Form

Part 1: Personal Information

Last Name
First Name
M.I.
Social Security Number
- -
Local Address Street
Phone Number
( )- -
City
State
Zip

Home Address Street
Phone Number
( )- -
City
State
Zip






Ethnicity

If other please specify here

Citizenship
Date of Birth
Sex


/ /
(mm/dd/yyyy)
Male Female

If not a US Citizen, do you have a Green Card? Yes (Must attach copy) No

What academic services programs do you participate in?
Cstep      SSSP        EOP       TOC      HONORS      NONE

Part 2: Eligibility (Check all that apply:)

Matriculated/ full time SUNY Brockport student with a 2.5 GPA or Better?

(1) Low income/first generation college educated (neither parent earned a bachelors
      degree)

(2) Underrepresented in graduate studies (minorities qualify in almost every
     
discipline)

No, I did not file and Income Tax Form nor was I claimed on one.

Yes, Copy of tax form must be enclosed.

Part 3: Statement Of Purpose

Respond to the following statement with an essay of 500 words or less in the area provided.
I would benefit from the McNair Program because......

You may wish to describe your past, present, and future educational experiences, career goals,
and research interests. Include any information you think may be helpful in considering your application.
Mention any academic honors or awards that you may have received.

Part 4: Academic Data

List the Graduate Schools you are considering:
Possible Mentor for research in McNair Program:
One letter or recommendation is needed from a professor in your major.
Please list the name and enclose a letter.
If not from a professor in your major, please explain why below.

Part 5: Certification Statement

All of the information on this form is true and complete to the best
of my knowledge. I authorize the Ronald E. McNair Program to
secure the financial and academic information necessary to determine
my eligibility and otherwise administer the program.
Signature___________________________________________          

Date_______________________

Please print this form SIGN and DATE in the appropriate locations,
and return the form to:

The Ronald E. McNair Post-Baccalaureate Achievement Program
Research Foundation of SUNY
SUNY College at Brockport Cooper Hall C-18
350 New Campus Drive
Brockport, New York 14420-2943