1. Name (please print or type)_________________________________________________________________________

   Social Security no. ________-______-________

   Mailing Address _________________________________________________________________________

   City____________________________________________ State ________________Zip_____________

   Phone (Work) ( ____ ) ______-_______ (Home) ( ____ ) ______-_______

   FAX ( ____ ) ______-_______

2. Degree program at BSU (or intended program) during assistantship:

   Department: _________________________________________________________________________

   Degree working toward: _________________________________________________________________________

3. Year assistantship requested:

   _____ 2001-2002 _____ 2002-2003 _____2003-2004

4. Academic Record (provide official transcripts and/or test score reporting forms)

   Undergraduate GPA: _______ Major: _____________ Minor _____________

   GPA in graduate courses: _______ Major: _____________ Minor _____________

   GRE Test Scores: Verbal _______ Quantitative _______ Analytical _______

   Other Test Score(s): __________________________________________________________

5. Present student status (See Item II)

   _____ I have not yet applied for the degree program.

   _____ I have applied, but have not yet been accepted.

   _____ I have been accepted into the degree program.

6. Brief explanation of reason(s) for requesting assistantship:

   1. _________________________________________________________________________

   2. _________________________________________________________________________

   3. _________________________________________________________________________

7. Three particular skills or professional experiences that would make you an effective graduate assistant in the Educational Leadership Department, a graduate degree granting department.

   1. _________________________________________________________________________

   2. _________________________________________________________________________

   3. _________________________________________________________________________

Signature ________________________________________________________________

Date ________________________

Note: Applicant should submit with this application: (1) letter of application; (2) official transcripts; (3) a curriculum vitae (CV); (4) three letters of reference describing specific qualifications for assistantship; and (5) additional evidence which addresses leadership, scholarship, and special qualifications that would contribute to the national stature of the department.

Please print, complete, and mail this form and all materials to: Graduate Assistant Chairperson, Department of Educational Leadership, Teachers College 918, Ball State University, Muncie, Indiana, 47306-0590