Applicant Name. Please indicate the number of the Service Area you are applying to serve: Area 0, Xxxxx Xxxxxx; Xxxx 0, Xxxxx Xxxxxx; Xxxx 0, Xxxxxxx/Xxxx Xxxxxx Service Area: Fixed Price per Mile
Applicant Name. Nombre del Aplicante: Street Address: Domicilio: Unit #: # de Unidad: City/Zip: Ciudad/Código Postal: Home Phone: Teléfono: Work or Daytime Phone: Número durante el día o del trabajo: When is the best time to reach you? ¿Cuándo es el mejor tiempo para llamarle? 🞏 Morning 🞏 Mañana 🞏 Afternoon 🞏 Evening 🞏 Tarde 🞏 Noche
Applicant Name. The potential faculty advisor for a student applying to the SHRS Health and Rehabilitation Sciences MS program must check statements below, as appropriate, and sign this form. I have communicated with this applicant and his or her research interests seem to align with mine. I have seen the complete application packet for this applicant and am satisfied with the student’s academic record and preparation. If this student is admitted, I will act as his or her advisor pending satisfactory progress in the program. I am requesting SHRS support to fund this student in year 1 (not required). I am requesting SHRS support in the form of a GTA (not required). If admitted, I plan to fund this applicant as follows (not required): Year 1 Year 2
Applicant Name. The potential faculty advisor for a student applying to the SHRS Health and Rehabilitation Sciences PhD program must check statements below, as appropriate, and sign this form. I have communicated with this applicant and his or her research interests seem to align with mine. I have seen the complete application packet for this applicant and am satisfied with the student’s academic record and preparation. If this student is admitted, I will act as his or her advisor pending satisfactory progress in the program. I am requesting SHRS support to fund this student in year 1. I am requesting SHRS support in the form of a GTA. If admitted, I plan to fund this applicant as follows: Year 1 Year 2 Year 3 Year 4 Agreement to act as a potential advisor is prerequisite to admission, but does not equal admission. Faculty may encourage multiple applications for each position they may have available. Once all applications are received, the faculty in conjunction with the Graduate Studies Committee will choose whether to admit each student based on academic qualifications, fit with the PhD program, and fit with the faculty member’s research. Therefore, a student may succeed in finding a potential advisor but not succeed in gaining admission to the program. If the prospective student is admitted, I agree to enter into an active, working partnership with the student and will provide accountable mentorship and be accessible to the student. I understand I will be responsible for guiding the student with curriculum choices, committee selections, program requirements, and overall professional development. Additionally, I am responsible for fostering rigorous PhD-quality scientific research that the student will engage in within my research program. Potential Advisor Signature (P status) Date
Applicant Name. OPA Account Number Please use the worksheet below and enter average monthly household expenses: HOUSING EXPENSES AMOUNT LIVING EXPENSES AMOUNT LIVING EXPENSES AMOUNT First Mortgage Telephone Car Loan Second Mortgage Groceries (exclude Food Stamps) Car Insurance Current Year Property Taxes Clothing Car Maintenance (oil changes, repairs) Homeowner’s Insurance Laundry Transportation (gas, SEPTA) Electric Service Toiletries and Paper Goods Child Support / Alimony Gas Service Housing Allowance (People in the home x $40) Tithe/Religious Donation (not more than 10% of income) Water / Sewer Service Other Household Goods Life Insurance Oil Service Medical and Dental Expenses Other Home Maintenance Medical and Dental Insurance Other Child Support/ Alimony Prescriptions Other HOUSING SUBTOTAL $ 0 LIVING EXPENSES SUBTOTAL $ 0 LIVING EXPENSES SUBTOTAL $ 0 $ 0 TOTAL OF ALL EXPENSES Ver 20180401 Owner Occupied Payment Agreement (OOPA) Expenses Worksheet Subtract expenses from your income to calculate tax payment amount $ 0 $ 0 $ 0
