DOCTORAL DEGREE PROGRAM

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1 DOCTORAL DEGREE PROGRAM Application Fo Admission National Mose Cente fo Adult Leaning Cental Illinois: Benedictine Univesity at Spingfield 1500 Noth 5th Steet, Spingfield, IL Phone: (217) Fax: (217) Web addess: ben.edu/mose Application fee waive code ADM staff appoval Date

2 Docto of Philosophy (Ph.D.) in Oganization Development (O.D.) APPLICATION INFORMATION 1. Send all mateials to the National Mose Cente fo Adult Leaning Benedictine Univesity at Spingfield,1500 N. Fifth Steet, Spingfield, IL A pesonal inteview with a doctoate faculty membe will be scheduled afte eceipt of all documents: Application fo admission and $50 application fee (non-efundable) Cuent esume (including petinent publications, pesentations and involvement in pofessional oganizations) Caee objective essay 3.Official tanscipts beaing the signatue of the egista and the institutional seal must be issued by diect mail fom the institution to the National Mose Cente fo Adult Leaning. Foeign cedit must be evaluated by Educational Pespectives at pespectives.og/benedictine o Education Cedential Evaluatos (ECE) at og. ECE epots must be a couse by couse evaluation of tansfe cedit. An official evaluation must be sent diectly fom ECE to Benedictine Univesity. Please contact the National Mose Cente fo Adult Leaning fo moe infomation. 4. Applications fo the Apil 2015 stat on the Spingfield banch campus ae accepted beginning Januay 1, All documents submitted become popety of Benedictine Univesity and will not be eleased to the student o any thid paty. 6. Students with a documented physical o mental disability may be eligible fo special accommodations though the Ameicans with Disabilities Act. Please contact the Student Success Cente fo moe infomation. GENERAL INFORMATION LAST NAME FIRST MIDDLE MOBILE PHONE OFFICE PHONE HOME PHONE OTHER NAMES MAIDEN (IF ANY) SOCIAL SECURITY NUMBER HOME COUNTRY STREET ADDRESS ADDRESS CITY STATE 9-DIGIT ZIP CODE RELIGION (OPTIONAL) COUNTY MARITAL STATUS MALE DATE OF BIRTH (MM/DD/YY) SINGLE MARRIED OTHER FEMALE Is English the pimay language spoken in the home? No Yes If no, please state language Ae you a U.S. citizen? No If yes, check one: By bith Yes By natualization (natualization cetificate numbe:) If no, ae you a U.S. pemanent esident/immigant/geen cad holde? No Yes If yes, please attach a copy of you pemanent esidency cad. Have you eve pleaded guilty o no contest to, o been convicted of, a felony? No Yes If yes, please povide date(s) and details ANSWERING YES DOES NOT CONSTITUTE AN AUTOMATIC BAR TO ADMISSION. FACTORS SUCH AS DATE OF THE OFFENSE, SERIOUSNESS AND NATURE OF THE VIOLATION AND REHABILITATION WILL BE TAKEN INTO ACCOUNT. NOTE: YOU ARE NOT OBLIGATED TO DISCLOSE THE EXISTENCE OF ANY CONVICTION OR ARREST RECORDS WHICH HAVE BEEN SEALED OR EXPUNGED PURSUANT TO CHAPTER 20, SECTION 2630/12 OF THE ILLINOIS COMPILED STATUTES. EDUCATIONAL HISTORY NAME OF HIGH SCHOOL MONTH/YEAR OF HIGH SCHOOL GRADUATION OR GED IMPORTANT: FAILURE TO LIST BELOW ALL SECONDARY SCHOOLS, UNIVERSITIES AND POST-SECONDARY INSTITUTIONS IN WHICH YOU ENROLLED (INCLUDING CORRESPONDENCE AND EXTENSION COURSES) MAY RESULT IN DELAY IN ADMISSION, LOSS OF TRANSFER CREDIT, AND/OR DISMISSAL. IT IS THE APPLICANT S RESPONSIBILITY TO HAVE OFFICIAL TRANSCRIPTS FORWARDED FROM EACH INSTITUTION IN WHICH YOU ENROLLED. AN OFFICIAL TRANSCRIPT IS REQUIRED EVEN IF ENROLLMENT WAS FOR A BRIEF TIME AND NO CREDIT WAS ESTABLISHED. NAME(S) OF ALL COLLEGE(S) ENROLLED AND CITY/STATE DATES ENROLLED DEGREE CONFERRED MAJOR MINOR GPA (Undegaduate & Gaduate Level) (check box if last school attended) Fo students with intenational postgaduate level cedits,* indicate yeas of full-time study instead of cedit hous: One yea o less Two yeas Thee yeas Fou yeas o moe *Students with cedits eaned outside the United States may be equied to have these cedits evaluated.

3 Will you have a postgaduate degee completed pio to enollment at Benedictine Univesity? No Yes EDUCATIONAL HISTORY (continued) If yes, what degee? I undestand that I must disclose all schools enolled and failue to do so can lead to the denial of admission, evoking of admission o administative withdawal fom couse enollment. Signatue Have you eve applied to any doctoate pogam at Benedictine Univesity? No Yes If yes, when? Have you eve enolled at Benedictine Univesity? No Yes If yes, dates enolled If yes, have you attempted any college cedit since attending Benedictine Univesity? No Yes Have you eve been suspended, placed on pobation o dismissed fom any high school o college? No Yes If yes, please explain the following on a sepaate sheet of pape: date of occuence, summay of incident, how you wee held accountable (outcomes, sanctions, etc.) and any additional infomation you wish to povide. Please note: additional infomation may be equested. ADMISSIONS INFORMATION When do you expect to ente Benedictine Univesity? How did you hea about Benedictine Univesity? Have you visited the Benedictine Univesity campus yet? No Yes LETTERS OF REFERENCE PLEASE ATTACH Submit two lettes of ecommendation, one pofessional and one academic that speak to you chaacte, capacity, pefomance and ability to do doctoal level wok with excellence. Please list the name, elationship and position of efeences below: NAME RELATIONSHIP POSITION NAME RELATIONSHIP POSITION ENTRANCE REQUIREMENTS Maste s degee fom an accedited institution. Fo intenational students, Test of English as a Foeign Language (TOEFL)/Intenational English Language Testing System (IELTS) of 550 (pape-based), o 78 (Intenet-based) and 6.0 IELTS. Date Taken PAPER-BASED TEST Scoe INTERNET-BASED TEST ESSAY STATEMENT PLEASE ATTACH WITH MOST CURRENT RESUME Please type you esponse to the following, double-spaced, one-to-five pages in length: Descibe how the Ph.D. fits with you long-tem caee objectives. Please include potential aeas of eseach inteest and any intenational wok expeience.

4 EMPLOYER INFORMATION Ae you cuently employed? No Yes Full Time Pat Time Ae you a vetean o cuently seving in the U.S. Militay? No Yes Ae you o have you eve been an employee of Benedictine Univesity? No Yes EMPLOYER/COMPANY NAME POSITION TELEPHONE WORK (OPTIONAL) ADDRESS CITY, STATE, ZIP COUNTY COUNTRY DESCRIBE YOUR CURRENT JOB RESPONSIBILITIES INTERNATIONAL STUDENT INFORMATION If you ae an intenational applicant fo a doctoal pogam planning to study unde a visa, please complete the following infomation showing equied citizenship and financial infomation. An intenational applicant is a citizen o pemanent esident alien of a county othe than that of United States. Any student who is a U.S. citizen o a U.S. pemanent esident with intenational cedit is consideed a domestic student and does not need to complete this page. County of citizenship: County of bith: City of bith: County of esidency: Ae you cuently in the U.S. on a visa? No Yes If yes to above, please indicate visa type: When does you cuent visa expie? Month: Day: Yea: Please indicate which school in the U.S. you ae attending: If you intend to tansfe you SEVIS ecod fom you cuent school, please fo citical infomation. Please send copies of the following documents: You cuent visa All I-20s and/o DS-2019s You cuent I-94* (font and back) I-94s, passpot photocopies and visas of all dependents *Electonic I-94s may be pinted fom I equest Benedictine to issue the following: I-20 (fo F-1 student visa). My pimay souce of funding will be a Benedictine assistantship, pesonal funds o funds fom family o fiends. (F-1 dependents will be issued F-2 visas.) DS-2019 (fo J-1 Exchange Visito/Student visa). My pimay souce of funding will be U.S. o home-county govenment o an intenational oganization. (J-1 dependents will be issued J-2 visas.) I do not need Benedictine documents because my sponsoing agency will issue (e.g. Fulbight). I will emain on visa (attach photocopies of you visa and I-94).

5 INTERNATIONAL STUDENT FINANCIAL SUPPORT FORM (fo F and J visa students only) Please complete all infomation equested in this section. I. Souce of Suppot I will pay fo school with my pesonal funds. I will be sponsoed by anothe individual, i.e. paents, family membe, othe sponso. I will be sponsoed by a govenment o oganization. Official documents in the fom of bank statements, cetified scholaships o awad lettes must be eceived and will not be etuned. II. Souce of Funds (Amounts in this section must match attached financial documents): Name of Account Holde: Name of Financial Institution: Addess of Institution: Name of Institution Official: Account Numbe: Sponsoing Oganization: Total Amount Available in USD: $ III. Student Declaation of Accuacy I cetify that the infomation given on this fom is complete and accuate to the best of my knowledge. I am fully awae that any false o misleading infomation will esult in disciplinay action and possible temination of my SEVIS ecod. Name Signatue Date READ CAREFULLY AND SIGN AS INDICATED REQUIRED I AGREE TO COMPLY WITH THE REGULATIONS AND REQUIREMENTS OF BENEDICTINE UNIVERSITY, AND TO COOPERATE WITH THE ADMINISTRATIVE OFFICERS, FACULTY AND MY FELLOW STUDENTS IN MAINTAINING HIGH STANDARDS OF CONDUCT AND SCHOLARSHIP AND IN PROMOTING THE GENERAL WELFARE OF THE UNIVERSITY. I UNDERSTAND THAT THE UNIVERSITY RESERVES THE RIGHT TO CANCEL THE REGISTRATION OF ANY STUDENT AT ANY TIME WHATSOEVER FOR REASON OF DEFICIENCY IN SCHOLARSHIP, UNSATISFACTORY CONDUCT OR FOR ANY OTHER JUST CAUSE. I AGREE TO PAY ALL FEES IN ADVANCE EACH TERM OR BY SPECIAL ARRANGEMENT WITH THE UNIVERSITY. I CERTIFY THAT THE INFORMATION I HAVE PROVIDED IS TO THE BEST OF MY KNOWLEDGE CORRECT AND COMPLETE. FAILURE TO PRESENT ACCURATE INFORMATION IN THIS DOCUMENT CAN LEAD TO THE DENIAL OF ADMISSION, REVOKING OF ADMISSION OR ADMINISTRATIVE WITHDRAWAL FROM COURSE ENROLLMENT. I HEREBY AUTHORIZE BENEDICTINE TO INVESTIGATE ANY STATEMENT CONTAINED IN THIS APPLICATION. I HEREBY RELEASE ANY PARTY FROM LIABILITY AS A RESULT OF ANY INFORMATION PROVIDED TO BENEDICTINE. IT IS UNDERSTOOD THAT I ACCEPT REGISTRATION AS A STUDENT AT BENEDICTINE SUBJECT TO THE ABOVE PROVISIONS. I UNDERSTAND THAT COMMUNICATIONS, INCLUDING UNIVERSITY FINANCIAL/STUDENT LOAN INFORMATION AND OTHER NOTIFICATIONS WILL BE SENT VIA MY BENU ACCOUNT. I ACCEPT RESPONSIBILITY TO MAINTAIN SAID ACCOUNT. (IF YOU PREFER TO RECEIVE PAPER NOTIFICATION, PLEASE SUBMIT A WRITTEN STATEMENT TO THE OFFICE OF FINANCIAL AID.) I GIVE BENEDICTINE UNIVERSITY PERMISSION TO USE MY LIKENESS IN PHOTOGRAPHS AND/OR VIDEO IN ANY AND ALL OF ITS PUBLICATIONS, INCLUDING WEBSITES AND PAGES, AND IN ANY AND ALL OTHER MEDIA, WHETHER NOW KNOWN OR HEREAFTER EXISTING, CONTROLLED BY BENEDICTINE UNIVERSITY, IN PERPETUITY, AND FOR OTHER USE BY THE UNIVERSITY INCLUDING BUT NOT LIMITED TO PROMOTING THE UNIVERSITY AND ITS PROGRAMS AND ACTIVITIES. ALL PHOTOS TAKEN ARE WITHOUT COMPENSATION TO ME (THE UNDERSIGNED). ALL ELECTRONIC OR NON- ELECTRONIC NEGATIVES, POSITIVES AND PRINTS ARE OWNED BY THE UNIVERSITY. Signatue of Applicant Date Fo additional infomation, please contact: National Mose Cente fo Adult Leaning, Cental Illinois (217)

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