University of Kentucky
Department of Curriculum and Instruction 
Application for Assistantship
 Teaching Assistantship      Research Assistantship
Name	     	     	     	     	
	Last	First	Middle / M.I.	Preferred Name	
Student ID	     	Date of Birth	     	Gender	 male     female	
Address	     	     	  	     	
	Street	City	State	Zip	
Phone	     	     	     	     	
	Home	Work	Other	E-Mail	
State Residence	     	Country Residence	     	Applying for	     -      Academic Year	
Area(s) of Teaching Certification	     	
Academic Status	
Degree Sought		Program	     	
Field of Specialization within the Department/Program	     	
Overall UGPA (4.0 scale)	     	Major Area	     	GGPA	     	
Degree expected between now and the beginning of the assistantship	     	     	     	     	
	Degree	Institution	Date	Field	
College Honors or Recognition:  Include scholarships/fellowships you have received as a graduate or undergraduate student;
List type, dates and granting institution.  You may attach a résumé if you wish.	
     	
	prior to
10-01-02	after
10-01-02				International Applicants Only	
GRE	Score	Score	Test Date		TOEFL	Score	Test Date	
Verbal:	     	     	MONTH YEAR			     	MONTH YEAR	
Quantitative:	     	     	If you have not yet taken the GRE, please indicate your anticipated scheduled date.			 paper based test
 computer based test	
Analytical:	     	     					
TOTAL:	     	     					
Languages other than English	
Speak:	     	Read:	     	
Relevant teaching, research, business, and/or work experience:  Please list most recent first.	
Employer	Place	Dates	Job Title or Duties	
     	     	     	     	
     	     	     	     	
     	     	     	     	
     	     	     	     	
References: 
List below three (3) people who are familiar with your academic and professional work. 	
Name	Field	Address	
     	     	     	
     	     	     	
     	     	     	
Include on a separate sheet any information which does not appear on this application
 that you feel will assist in evaluating your request.
Applicant Signature	     	Date: