Grant Application

M.S. Computer Information Science Program 

Please print out and print your information or copy and paste into a Word document.

Date _____________

Applicant _____________________________________________________________                                                   first                           middle                          last

Address ______________________________________________________________

_____________________________________________________________________

La Salle ID Number _______________

Telephone Number:  day _______________________ evening __________________

E-Mail Address:  _______________________________________________________

If not an American citizen, Visa code  _____________________________________

Current Status:

  _____ New Application for Admission
  _____ Current M.S. CIS Student

Graduate GPA  _________     

Graduate CIS courses completed__________________________________________

Course(s) during semester of award   ______________________________________

Semester applying for  __________________________________________________

Employer:

Company Name ____________________________________________

Address __________________________________________________

_________________________________________________________

Phone Number ____________________________

Do you receive any reimbursement moneys through your employer? Yes _____  No  _____

If yes, what is the start of the employer fiscal year for the reimbursement? ________

If your employer does provide some reimbursement money:

Amount of employer contribution for semester of grant  ________________________

Amount of your tuition not covered by employer for semester of grant ____________

Applicant’s Signature ______________________________ Date __________________