Disclaime
(Summer
Last Nam
Telephon
Major: __
Expected
Classificat
List specia
clubs, org
which you
________
________
________
Most pos
that woul
Select one
________
________
________
I give perm
records. (S
Signature
er: Being selec
Intern, Co-op
e: _________
e: _________
____________
Graduation D
tion: (Select o
al academic h
ganizations, e
u have partic
____________
____________
____________
itions at Rayt
ld prevent yo
e:
____________
____________
____________
mission to the
Sign by initial
e of Applicant
Dep
Raytheo
cted to partici
p, or Full time)
___________
___________
___________
Date: ______
one)
honors, speci
extracurricula
cipated:
___________
___________
___________
theon require
ou from gettin
___________
___________
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e Department
ling below)
t: _______
partment o
Southe
on Mentor
ipate in the M
) with Raythe
___________
____________
___ Degree:
____________
ial recognitio
ar activities a
____________
____________
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e a Departme
ng a clearanc
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____________
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t of Compute
of Comput
ern Univer
ring Progra
Mentoring Pr o
eon Company
First Name:
__ Email:
___________
_______
on, scholarshi
nd communi
___________
___________
___________
ent of Defens
ce? (If your an
___________
___________
___________
r Science Com
ter Science
rsity
am Applica
ogram does n
y
: __________
__________
___________
ips, and/or aw
ty activities a
___________
___________
___________
se security cl
nswer is 'Yes
___________
___________
___________
mmittee to re
e
ation
not guarantee
____________
____________
_______ Over
wards you ha
and commun
____________
____________
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earance. Is th
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view all of my
e a position
_______ MI:
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rall GPA: ___
ave received;
nity activities
___________
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here anythin g
lain)
___________
___________
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y academic
____
_____
_____
;
in
_____
_____
_____
g
_____
_____
_____
Freshman Sophomore Junior Senior
Yes (Please Explain) No
