APPLICATION TO THE
REHABILITATION ENGINEERING TECHNOLOGY
CERTIFICATE PROGRAM

APPLICATION PROCESS
All applications will receive serious consideration. We have a particular interest in recruiting people with disabilities into this project. We also encourage women and people of color to apply. If you are interested in joining our project, see the application information below and/or contact us and we will send an application pack. Please feel free to contact us with any questions.

Note: This is not an application for admission to the university. You must file an official application separately through the University Admissions Office unless you are already enrolled as a graduate student in the University. (Along with their standard application form, the univerisity will request transcripts from previously-attended colleges or universities.) For more information, go to University Admissions or call the Graduate Division office at 415/338-2235.

The following replicates the content of the RET Project application form. You can copy this material and send us the responses in any reasonable format (in the order presented) or contact us to receive a printed version.

Application to the RET Training Program

1) Date:

PERSONAL INFORMATION

2) Name:
Last name (please print)
First name
Middle name

3) Address:
Street name and number
City
State
Zip Code
Telephone: ( )

4) Date of Birth:
5) Ethnic/Racial Identity (optional) :
6) Do you have any physical disability? Yes, No
If yes, describe the nature of the disability:

7) Indicate if you are applying for a one-time stipend ($5,000 to $7500).
(If you are applying for a stipend, you must plan on being a full-time student for two semesters. The terms of the Federally funded stipend require that you begin working for two years for a non-profit or state agency within 2 years of graduation or repay the money.)

8) ACADEMIC BACKGROUND:

(Please list all training since high school with the most recent institution first.)
Name & Location Of Institution
Dates of Attendance
Major
Overall GPA
Degree Earned (if any)

9) WORK EXPERIENCE:
Provide the following information for each company or agency that you have worked for within the last ten years:

Name & Location of Company
Dates of Employment
Nature of Work
Paid or Volunteer
Part or full time

10) REFERENCES:
Please distribute a copy of the attached reference form to three persons who are familiar with your qualifications, preferably university instructors and/or employers. List the people to whom you are sending reference forms below.

It is your responsibility to be certain that the reference is sent directly to the Rehabilitation Engineering Project. You should give these individuals a correctly addressed, stamped envelope.

RECOMMENDATION 1
Name
Position
Address
Phone #

RECOMMENDATION 2
Name
Position
Address
Phone #

RECOMMENDATION 3
Name
Position
Address
Phone #

11) PROFESSIONAL AND CAREER GOAL STATEMENT
Please provide a statement indicating those factors in your personal, educational and/or occupational background and experiences which have led you to seek a career in assistive technology or to enhance your current career goals and activities with this knowledge. Personal background may include such areas as significant others, attitudes, and values. Your statement should also include your plan to fit your graduate training into your life and any other factors which you feel would be helpful in our evaluation of you. Limit your statement to no more than three double spaced, typed pages.

SEND APPLICATION TO:

RET Project
College of Health and Human Services
1600 Holloway Avenue
SF CA 94132

FAX: 415-338-1501

QUESTIONS?
Ray Grott
415-338-1333, rgrott@sfsu.edu

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