UCLA CHEMISTRY & BIOCHEMISTRY DEPARTMENTAL APPLICATION

____________________________, ___________________________ ____________________
(Last name, First name, Middle name)

U.S. Social Security Number ______________________________ ¬…

Date of Birth _________________

Gender:
____ Male
____ Female

Day Phone __________________________ ¬… Evening Phone ___________________________

Mailing Address

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________


Permanent Address and Phone

____________________________________________________

____________________________________________________

____________________________________________________

____________________________________________________

( ________ ) _________________________________________


E-mail Address
_____________________________________________________________________

PLEASE PRINT CLEARLY!

---

Academic Information

Undergraduate University _______________________________________

Undergraduate GPA ________________

Undergraduate Degree (please circle) BS BA AB Other _____

Year Conferred or Expected ____________

Graduate University ___________________________________________

Graduate GPA _______________

Graduate Degree (please circle) MS MA PhD Other _____

Year Conferred or Expected ____________

Test dates:

• GRE General _____________
• GRE Subject _____________
• TOEFL _________________
• TSE ___________________

Test scores:

GRE General

• Verbal _________ (percentile) __________ (score)
• Quant _________ (percentile) __________ (score)
• Analy _________ (percentile) __________ (score)

GRE Subject ________________ (percentile) _______________ (score)

TOEFL _______________

TSE __________________

---

Supplemental Information

Are you a California resident?
____Yes
____ No

Are you a U.S. citizen?
____ Yes
____ No

If not a US citizen, please indicate your visa type:

____ Student/F-1
____ Refugee/RF
____ Exchange/J-1
____ Immigrant/IM
____ Permanent Resident/PR

Country of Citizenship:_______________________________________

Ethnicity (please check all that apply):
____ American Native/Alaskan native
____ Black/African American
____ Chicano/Mexican American
____ Chinese/Chinese American
____ East Indian/Pakistani
____ Filipino/Pilipino
____ Japanese/Japanese/American
____ Korean/Korean American
____ Latino/Latin American
____ Other Hispanic
____ Polynesian
____ Puerto Rican
____ Thai/Other Asian
____ Vietnamese
____White/Caucasian
____ Other (please specify) __________________________

---

Program to which you are applying (check one) :

____ Biochemistry

____ Chemistry

Chemistry area of specialization (check one)

____ Physical

____ Organic

____ Inorganic

Brief description of research interests:

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________