Internship Application

Please Print or Type

Last Name  First Name Middle Name

Present Address  Apt

City State Zip Code

Telephone E-Mail  

 

Permanent Address (If Different)    Apt

City State Zip Code

Telephone E-Mail  

Legal State of Residence  

Country of birth, if other than USA: 

If permanent registered alien, Registration #

Date of Birth

Social Security Number

Sex: Male Female

Ethnicity: Asian/Pacific Islander African-American/Black White/Caucasian

Hispanic/Latino Native-American Indian/Alaskan Other

 

Education:

School Currently Attending

Class Level Expected Date of Graduation

Major Intended Career 

Pre-Professional Program of Study

(i.e.: Pre-Med, Pre-Dental, Pre-Optometry, etc.)

Overall GPA   Science GPA Math GPA  

SAT Scores: Verbal Math

Parental Information:

Father's Name

Mother's Name  

Total Annual Family Income

Sources of Income

Number of Members in Household

Have you ever participated in any of the following State-sponsored programs?

STEP CSTEP HEOP EOP SEEK College Discovery Other (Name)

If you participate in any of the above programs at your school, please give:

Director or Coordinator's Name 

Telephone 

NOTE: Being a member of CSTEP at another College does not preclude you from participating in SUNY Optometry's CSTEP Internship Program.

Have you ever had your eyes examined by an optometrist? Yes No

Have you ever spoken to an optometrist about his/her profession? Yes No

In no less than 100 words, in the following space (or on a separate sheet of paper), please answer the following question: (Please type or write neatly)

From what you already know about optometry and have read in our CSTEP brochure, please explain how the CSTEP Internship Program will benefit you in your professional pursuits?

    

Additional Documents Needed:

1.  Current College Transcript (including up to Spring & Summer 2007 Grade Reports)

2.  Current class schedule or course registration.

3.  If you have not participated in other CSTEP or State-sponsored programs, please submit documents verifying household income (i.e.: 2006 IRS 1040 forms).