DATE __________________________________

NAME _________________________________                       UNI____________________

EXPECT TO GRADUATE IN (mo/yr): ______________     SCHOOL _______________

LOCAL ADDRESS __________________________________________________________

LOCAL TELEPHONE _______________         
      
PERMANENT ADDRESS ____________________________________________________

SUMMER ADDR/PHONE ___________________________________________________

NUMBER OF CREDITS COMPLETED (as of this May)_________  G.P.A. ___________  

MAJOR ______________________  2nd MAJOR/CONC __________________________

DEPT. FACULTY ADVISOR who knows you:___________________________________
  (or other psych. dept. member)

FIELD(s) OF INTEREST WITHIN PSYCH/NEUROSCIENCE: _____________________
 (e.g., social, neuroscience, cognition, etc.)

LIST ALL PAST and PRESENT MAJOR COURSES AND GRADES:*

Psychology or Neuroscience

Grade

Course

Received

1)_________________________________

__________

2)_________________________________

__________

3)_________________________________

__________

4)_________________________________

__________

5)_________________________________

__________

   * Please attach a copy of your most recent Columbia transcript. Transfer students, please include a transcript from your previous college/university.

On a separate page please:

• Describe any research experience you have had.
• Provide a brief statement of why you would like to be admitted to the Honors Program.
• Describe your plans for after graduation.