Last Name First Name Middle

Home Address

City State Zip

Home Phone Number

Ethnicity (optional) Gender

Country of Citizenship

Expected graduation year Birthdate

e-mail address

High School School Phone Number

Current GPA Class Rank

Parent(s) or Guardian(s) name(s)

Daytime Contact number(s)

Evening or weekend contact number(s)

Fill in the scores of standardized tests taken:

Test	Raw Scores	Percentile Rank	Date Taken
PSAT	Verbal Math	Verbal Math
SAT	Verbal Math	Verbal Math
ACT
Other

 

SELECTION OF SCIENCE DEPARTMENTS: As much as possible, students are matched to
professors who are working on research in which the student has expressed an interest. Please rank
your top three preferences of the choices listed below. Fill in the blanks for your three choices. (Choose a total of three, not three in each category.) Although we cannot guarantee
positions will be available in all of these fields, we make every effort to place students in their chosen
areas.

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From the list below type in your choices

1st Choice

2nd Choice

3rd Choice

Engineering:

Biomedical
Chemical
Civil
Environmental
Electrical
Mechanical

Lifeand Health Sciences:

Biological Science
Biochemistry
Ecology
Exercise Science
Internal Medicine
Microbiology
Neurology
Pathology
Pediatrics
Speech Pathology

Physical Sciences:

Chemistry
Geology
Physics & Astronomy
Mathematics

Other

Archaeology
Urban/Regional Planning
Psychology
Computer Science
Public Health

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If you take the course for 3 credit hours, you will be billed an additional ~$850 by the University of Iowa. If you take it for 0 credit hours, you only need to pay the program fee. Please indicate below(with an x) if you intend to participate in SSTP for 3 hrs of UI credit or 0 hrs of UI credit.

0 credit hours
3 credit hours