Student Information Form | University of Maryland Eastern Shore Marketing Retarget Pixel

Student Information Form

  •  
    Date:
    Student contact Information 
    First Name:  
    Middle Name:   
    Last Name:  
    Suffix:  
    Home Address   
    Address Line one:  
    Address Line two:  
    Town/City:  
    State:   
    Zip Code:  
    Local Address  
    Address Line one:  
    Address Line two:  
    Town/City:  
    State:  
    Zip Code:  
    Contact Information
    Cell Phone:  
    University Email Address:  
    Non-University Email Address:  
    Citizenship  
    If U.S. Citizen, you must show proof of citizenship.
    Only a valid U.S. Passport, Certified U.S. Birth Certificate
    or Certificate of Citizenship (Naturalization) are acceptable proof.
    Please indicate which document you will be using: 
    Ethnicity and Gender Information
    Ethnicity:
    If other:  
    Gender:
    Student Academic Information
    Date started current degree:
    (Use this format for the date:  mm/yyyy)  
     
    Academic Institution you attend:
    If other:  
    Degree Program:
    Faculty Mentor:  
    Major:  
    Area of Concentration:  
    Research Title or Topic:  
    Primary Research Advisor:  
    NOAA Research Advisor:  
    Current Classification and Year of Study:
    Current, cumulative GPA:  
    Expected Graduation Date:  
    Program Association  
    Which program are you most closely associated with:  
    If other:   
    Transfer Students Only  
    Previous Institution:  
    Degree Sought:
    Date Started at Previous Institution:   
    How many years did you study at previous institution?
    Career Goals  
    When I graduate I plan to:  
    If other:  
    How did you hear about LMRCSC opportunities?  
    If other:  
       
    ACADEMIC DEVELOPMENT PLAN 
    Suggested entries: List of courses to be taken, planned teaching experiences (e.g. undergraduate lab classes), and graduate committee meeting dates.
    Year 1: 
     
    Year 2:  
     
    Year 3: 
     
    Year 4: 
     
    Year 5:   
     
    CAREER DEVELOPMENT PLAN
    Suggested entries: Student’s planned research experiences (e.g., REUs or thesis research), seminars to attend (e.g. LMRCSC or NOAA seminars); professional development workshops to attend (e.g., Teaching Effectiveness or a GIS workshop), professional activities (e.g., meetings or seminars a student will attend/present); participation in professional organizations (e.g., AFS), participation in academic service (e.g. university committees), participation in community service (e.g. mentoring K – 12 students at local schools or volunteering with a local community organization).
    Year 1: 
     
    Year 2: 
     
    Year 3: 
     
    Year 4:  
     
    Year 5: 
     
    SOCIAL AND PERSONAL DEVELOPMENT PLAN
    Suggested entries: Student participation in a professional development workshop that strengthens their “soft skills” or personal skills (e.g. stress management; leadership skills); student learns to develop a professional profile on an established professional site (e.g. LinkedIn).
    Year 1: 
     
    Year 2:  
     
    Year 3:  
     
    Year 4:  
     
    Year 5: