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__________________________________ Social Security Number: Name of employer or college: _________________________________ Emergency Contact: Name: ____________________________ Address: _____________________________________ Phone: ___________________________ ___________________________________ Day Phone: _______________________ Evening Phone: ________________________Fax: ____________________ e-mail: __________________________________________________________________________________________ Sex: Male Female Date of Birth (Month/Day/Year): ______________________ Citizenship: U.S. U.S. Permanent Resident (submit copy of both sides of alien registration card) Non-U.S. (proof of status required upon arrival) Country of Citizenship: ____________________________________ Country of Birth: _________________________________ What factors influenced you to apply to Stevens? ______________________________________________________________ _______________________________________________________________________________________________________ DEGREE OBJECTIVE Part-Time Full-Time PLEASE CHECK ONE: Graduate Certificate Master s Degree Engineer Degree Ph.D. Non-matriculating PROGRAM/CONCENTRATION MUST BE COMPLETED. REFER TO PROGRAM LIST. Academic Program: _________________________________ Concentration: ____________________________________ Entry Term: Fall 20___ Spring 20___ Summer I 20___ Summer II 20___ If you plan to enroll in an off-campus location, please specify location: ________________________________________ EDUCATIONAL HISTORY Please list previous colleges attended in chronological order College(s) Town, State Dates AttendedDegree(s)Date Awarded (or expected)MajorGPA  GRE or GMAT (if required) Test dates taken or planned: ______________ Scores: V ______ Q ______ A ______ PROFESSIONAL EXPERIENCE Please list employment experience in chronological order. CorporationTitleTown, StateNo. of YearsResponsibilities FOR ALL STUDENTS (OPTIONAL) These questions are included so that Stevens can comply with U.S. Department of Education reporting procedures. None of the information provided serves as a basis for admission. How would you describe yourself? (Please check one) o American Indian or Alaskan Native o Hispanic o Asian or Pacific Islander o White (non-Hispanic) o Black (non-Hispanic) o Other FOR INTERNATIONAL STUDENTS (REQUIRED) % Are you currently in the United States? o Yes o No If yes, What is your current immigration status?_ _______________________________________________________________ What is your 11-digit departure number? (indicated on the white I-94 card in your passport):______________________________ ___________ _ % Country from which you hold a passport:_________________________ ________________ Expiration Date: ____/____/________ % Are you requesting documents to apply for o (F-1) or o (J-1) from Stevens? If neither, explain: ________________________________ % Submit PHOTOCOPIES OF ALL IMMIGRATION DOCUMENTS (These may include current immigration forms, passport, visa and I-94.) % Submit GRADUATE FINANCIAL VERIFICATION FORM or I-134 (Graduate Financial Verification Form  FVF or I-134 is required from all international students intending to apply for or maintain F-1 or J-1 visa status. Before required immigrations forms can be issued, certification of financial resources is required.) % Submit RECENT TOEFL SCORE (Test of English as a Foreign Language) Score_______ Test dates taken or planned: __________  I understand that enrollment is dependent upon my submitting ALL supporting documentation for this application. All documents submitted become part of Stevens files and cannot be returned to me. My signature below indicates that all the information contained in my application is factually correct and honestly presented. Signature: _____________________________________________________________ Date: _______________________________ OFFICE OF GRADUATE ADMISSIONS Stevens Institute of Technology Castle Point on Hudson Hoboken, NJ 07030 ph: 201.216.5234 fax: 201.216.8044 e-mail: gradadmissions@stevens.edu www.stevens.edu b.b8b:bFbJb^bjblbvbxbbbbb~ccdddd^dtdddddde(e`enee¬¬ꘂkR0hh6hcmB*CJKHOJQJ^JaJo(ph-hh6hcmB*CJKHOJQJ^JaJph*hcmB*CJKHOJQJ^JaJo(ph'hcmB*CJKHOJQJ^JaJph*hcmB*CJ KHOJQJ^JaJ o(ph'hcmB*CJ KHOJQJ^JaJ ph'hcmB*CJ KHOJQJ^JaJ ph*hcmB*CJ KHOJQJ^JaJ o(ph e>frfffZgdgggh$hjhlh6i8iiij jjj"jbjjjjjj*kkkkkllmmnnn몓yyd)hcm5B*CJKHOJQJ\^Jph3hh6hcm6B*CJKHOJ QJ ]^J aJph-hh6hcmB*CJKHOJQJ^JaJph-hh6hcmB*CJKHOJQJ^JaJph'hcmB*CJKHOJQJ^JaJph*hcmB*CJKHOJQJ^JaJo(ph'hcmB*CJKHOJQJ^JaJph'nnnnnnnnno oo8oDoHofojolotoxooooooooooo6pvJvlvnv$$7$8$H$Ifa$gdcml' $7$8$H$a$gdcm nvpvrvtvvvxvN4444$$7$8$H$Ifa$gdcmlkd;$$Iflr>u (QRRRR t0644 laxvzv|v4kd$$Iflr>u (QRRRR t0644 la$$7$8$H$Ifa$gdcml|v~vvvvv$$7$8$H$Ifa$gdcmlvvvvvvN4444$$7$8$H$Ifa$gdcmlTkd7$$Iflr>u (QRRRR t0644 lavvv4kd$$Iflr>u (QRRRR t0644 la$$7$8$H$Ifa$gdcmlTvvvvvv$$7$8$H$Ifa$gdcmlvvvvvvN4444$$7$8$H$Ifa$gdcmlkd3$$Iflr>u (QRRRR t0644 lavvvvw4(( $7$8$H$a$gdcmkd$$Iflr>u (QRRRR t0644 la$$7$8$H$Ifa$gdcmlvFxJxxxxx y"y&y8y`ydyyyyzz z4zFzJzVzXzZz\zϻ觻z[F)hcm5B*CJKHOJQJ\^Jph=jhcm5B*CJKHOJQJU\^JmHnHphu,hcm5B*CJKHOJQJ\^Jo(ph*hcmB*CJKHOJQJ^JaJo(ph'hcmB*CJKHOJQJ^JaJph'hcmB*CJKHOJQJ^JaJph0hcm6B*CJKHOJ QJ ]^J aJo(ph-hcm6B*CJKHOJ QJ ]^J aJphwHxJxxyVzXzz{{} ~ $7$8$H$VDr^a$gdcm$7$8$H$WD`a$gdcm$7$8$H$WD`a$gdcm $7$8$H$a$gdcm\zbzdz~zzzzzzzzz{{ { {{x{z{{{J|Ӻ||eQ;*hcmB*CJKHOJQJ^JaJo(ph'hcmB*CJKHOJQJ^JaJph-hQuhcmB*CJKHOJQJ^JaJph'hcmB*CJKHOJQJ^JaJph'hcmB*CJKHOJQJ^JaJph*hcmB*CJKHOJQJ^JaJo(ph0hOhcmB*CJ KHOJQJ^JaJ o(ph)hcm5B*CJKHOJQJ\^Jph-hcm5B*CJKHOJQJ\^JaJphJ|||}} } }}}}f}}}}}} ~ ~~~j~n~~~~~εrεr^rJrJrr'hcmB*CJKHOJQJ^JaJph'hcmB*CJKHOJQJ^JaJph'hcmB*CJKHOJQJ^JaJph*hcmB*CJ KHOJQJ^JaJ o(ph0hOhcmB*CJ KHOJQJ^JaJ o(ph0hcm6B*CJKHOJ QJ ]^J aJo(ph3hQuhcm6B*CJKHOJ QJ ]^J aJph-hcm6B*CJKHOJ QJ ]^J aJph$ DFʅ̅ "ֿ~h֒Jhhhh;jhcmB*CJKHOJQJU^JaJmHnHphu*hcmB*CJKHOJQJ^JaJo(ph'hcmB*CJKHOJQJ^JaJph0hOhcmB*CJ KHOJQJ^JaJ o(ph'hcmB*CJKHOJQJ^JaJph-hcm6B*CJKHOJ QJ ]^J aJph'hcmB*CJKHOJQJ^JaJph*hcmB*CJ KHOJQJ^JaJ o(ph"$ 26vzdhԾԾԪԪԪԖԖԖԖԖ,hcmhcmB*CJKHOJQJ^Jo(ph'hcmB*CJ KHOJQJ^JaJ ph'hcmB*CJ KHOJQJ^JaJ ph*hcmB*CJKHOJQJ^JaJo(ph'hcmB*CJKHOJQJ^JaJph-h|hcmB*CJKHOJQJ^JaJphЇ $7$8$H$a$gdcm6182P:pcm. 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