Name:___________________________________________
 

Date of initiation:        March 2008
 

Current GPA as per most recent grading period:  ________
 

Current GPA in Rutgers Camden history courses:  _______
 

How many Rutgers Camden history courses have you taken?  _______
 

Permanent Address  (Required for mailing The Historian):

___________________________________
 

___________________________________
 

____________________________________  (ZIP CODE REQUIRED)
 
 

Phone:_______________________________
 
 

E-Mail:_______________________________
 
 

School address and phone (if different from permanent address):
 

________________________________________
 

_________________________________________
 

_________________________________________
 
 

UNDERGRADUATE RECORD:

Schools attended and Dates:
 

_________________________
 

_________________________
 

_________________________
 
 

GRADUATE RECORD:
 

Schools attended, degrees, and dates:
 

_______________________________
 

_______________________________
 

_______________________________
 
 

Scholarly Achievements:  (Awards, publications, jobs, etc.)
 

(Use the back of this page if necessary to complete list)