The Graduate School 
The University of Tennessee
18637
On-Line Graduate School Application System SSN:   413 - 81 - 4868
Signature and payment form Name:   Basuki Setio
  Address:   489 Bedford Ave.
Instructions: Read this form, print it out, City, State Zip:   Uniondale NY11553
sign it and mail it along with your payment. Email Address:   basukis@yahoo.com
You must print the entire form down to the line that Phone:   (516)483-0051
says ==This line must be included on your form==. Birthdate:   03/23/1968
REMEMBER TO ALSO REQUEST YOUR OFFICIAL TRANSCRIPT(S).      

I understand that withholding information required in this application or giving false information may make me ineligible for admission to, or continuation in, The University of Tennessee. With this in mind, I certify that the statements which I have made in my on-line application to The University of Tennessee Graduate School are correct and complete. I also confirm that I will adhere to the Honor Statement as printed on this form and that I have registered for or am not required to register for the federal draft.

Date ______________________ Signature ______________________________

  Circle one of these payment options:
   
(option 1) $35.00 application fee enclosed (non-refundable) (Check payable to University of Tennessee)
   
(option 2) No fee required - Attended Graduate School within UT System
Paid: __________________________________
  Campus Date
   
(option 3) No fee required - Paid to UT Graduate School on the Knoxville campus within past 12 months.
   

HONOR STATEMENT
An essential feature of The University of Tennessee, Knoxville is a commitment to maintaining an atmosphere of intellectual integrity and academic honesty. As a student of the University, I pledge that I will neither knowingly give nor receive any inappropriate assistance in academic work, thus affirming my own personal commitment to honor and integrity.

The University of Tennessee, Knoxville does not discriminate on the basis or race, sex, color, religion, national origin, age, disability, or veteran status in provision of educational programs and services or employment and benefits. This policy extends to both employment by and admission to the University.
The University does not discriminate on the basis of race, sex or disability in the educational programs and activities pursuant to the requirements of Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Americans With Disabilities Act (ADA) of 1990.
Inquiries and charges of violation concerning Title VI, Title IX, Section 504, ADA, or the Age Discrimination in Employment Act (ADEA) or any of the other above mentioned policies should be directed to the Office of Diversity Resources and Educational Services (DRES); 1818 Lake Avenue, The University of Tennessee, Knoxville, Tennessee 37996-3650, telephone (423)974-2498 (TTY available). Requests for accommodation of a disability should be directed to the ADA Coordinator at the Office of Human Resource Management, 600 Henley Street, Knoxville, TN 37996-4125.
Return this form to:

Graduate Student Services
218 Student Services Building
Knoxville, Tennessee 37996-0220

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