Please Print or Type:

Name:__________________________________________________Date of Application:____________

Mailing Address: _____________________________________________________________________

Phone:(______)____________________________ SS#:_______-_____-________

1. Program and Admission Date for which you are applying (Check one and Specify Date):

Clinical   ___    Experimental ____ Date of enrollment: Fall or Spring 200__

2. Have you previously applied to this Graduate Program?

 Yes_____________No _____________

3. Provide the name, title, and address of each of the three persons to whom you have submitted recommendation forms:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Click here for a Copy of the Recommendation Form

4. Provide a list of professional or student memberships in learned and professional organizations:

        ________________________________________________________________

        ________________________________________________________________

5. Provide titles of publications, presentations, major papers, or theses of which you are author or coauthor. Give citations.  Reprints of publications may be enclosed but cannot be returned:

        _______________________________________________________________

        _______________________________________________________________

        _______________________________________________________________

6. Please give relevant volunteer or work experience you have had, including the employer's name, work performed, and duration of employment:

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

7. I intend to be enrolled as a ___Full Time (9-12 SCH) or Part-time student (<9 SCH)

8. Please complete and attach a 500-word essay in English, in which you describe your professional goals and objectives.

      I certify that the information in this application is complete and correct to the best of my knowledge and belief, and that the omission of information or submission of any false information is grounds for rejection of my application, withdrawal of any offer of acceptance, or dismissal after enrollment.

_____________________________________________________
SIGNATURE                                                       DATE

Please note that unsigned applications will not be considered. Note that you also need to apply to the Graduate School at UTPA and be accepted, prior to acceptance into the Graduate Psychology Program. An application for addmission to the UTPA Graduate School may be obtained from the Office of Admissions and Records at the University. Mail this completed Graduate Psychology application to: