2023-2024 Student Regent Application

Directions for Completing and Submitting the Application

•	Please print or type your information.

•	Applications must be received by the Student Government Association no later than:
December 2, 2022 at 5:00 p.m.

•	Applications received after the deadline will not be eligible for consideration.

•	Electronic and facsimile applications will not be accepted.

•	Upon completion of the UNT System Student Regent Application and the Office of the Governor Appointment Application, each applicant should deliver the original, signed copies of both applications in person or by mail to:
University of North Texas Health Science Center
Division of Student Affairs
c/o Lori Saunders, Director, Student Services
3500 Camp Bowie Blvd. 
Fort Worth, TX 76107

This application may be subject to disclosure under the Texas Public Information Act. By signing this form, applicant waives any exemption from disclosure afforded by the Family Educational Rights and Privacy Act, 12 USC 1232g, with the exception of a Student Identification Number which will be confidential unless otherwise provided by FERPA.

Personal Information

1.	Name of Student:

First	MI	Last
2.	University you are currently attending:

3.	Student ID #:

4.	Campus Mailing Address:
5.	Campus Telephone Number:

6.	E-mail Address:

7.	Are you a Texas resident?	Yes	No
1.	
Personal/Permanent Information, if different from above (winter/summer break contact)
1.	Mailing Address:

2.	Cell Phone Number:

Educational Background
1.	Please indicate your class standing as of the 2022 Spring Term:
Sophomore	Junior	Senior	Graduate
2.	Will you be enrolled as a student at this university continuously through the 2023-2024 academic year?	Yes	No

3.	What is your Major?		Minor?   	
4.	What is your intended degree and expected year of award?   	
5.	What is your GPA as of the latest completed semester?
6.	To the best of your knowledge, are you in good standing at the present time with the university in all respects, with no delinquent financial obligations or pending disciplinary actions?	Yes	No

7.	Have you been disciplined while attending this, or any other university, for infractions of university policy?	Yes	No

8.	List all colleges or universities you attended below and include the dates you attended, semester credit hours completed, and any degrees you were awarded:

Institution Attended	Dates Attended	Semester Credit Hours
Completed	Degree Awarded	

				

References
Provide references below (limit three). One of your references must be a faculty member of a UNT System institution who is familiar with your academic work and/or extracurricular leadership. Please notify your references at the time you submit this application that they may be called or asked to submit a letter of reference. Letters of reference are not required at this time.

Name and Title	Relationship to Applicant	
E-mail Address	
Telephone Number	

				

Student Activities and/or Social Organizations

List participation in student activities and social organizations at this or other higher education campuses. Include beginning and end dates of your participation and note any leadership positions held.

Community Service and/or Civic Organizations

List participation in community service or civic organizations. Include beginning and end dates of your participation and note any leadership positions held.

Other Relevant Experience

List any other experience you deem relevant to your ability to serve as a student regent.

Brief Essay

In 250 words or less, explain your interest in serving as the student regent and identify the key issues you believe should be addressed by the Board of Regents. Attach additional sheets if needed.

I hereby certify that the foregoing and any attached statements are true, accurate and complete. I agree that any misstatement, misrepresentation, or omission of a fact may result in my disqualification for appointment. I assign and hereby give the University of North Texas System full authority to conduct background investigations pertinent to this application.

The student applicant is in good standing with this office and, to the best of my knowledge, has met all obligations to which he/she has committed to the university.

Office of the Dean of Students:

Yes

No

Initials:		Date:   	

Office of the Bursar:

Yes

No

Initials:		Date:   	

Office of the Registrar: (verify GPA provided above):

Initials:	Date:    	

NOTE: Applicants must have a GPA of 2.5 or higher to be considered for the student regent position.

Signature of Applicant:	Date: