MASTERS OF SCIENCE IN ADMINISTRATION (MSA) APPLICANT CHECKLIST

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1 California State University, Bakersfield EXTENDED UNIVERSITY DEGREE PROGRAMS 9001 Stockdale Highway 30BDC Bakersfield, California Phone Fax MASTERS OF SCIENCE IN ADMINISTRATION (MSA) EXTENDED UNIVERSITY DEGREE PROGRAMS APPLICANT CHECKLIST Directions to Applicant: Before mailing your application, please read and check the following points: Fill out application form completely Transcripts: One official transcript showing all undergraduate and graduate coursework from each institution attended must be submitted with your application. We would suggest you have all transcripts sent to yourself and submit unopened copies along with your application in one packet. Application/Evaluation Fee: If you are applying to a degree or credential program, submit a non-refundable Application Fee of $75.00 with this application payable to California State University, Bakersfield. Three MSA Graduate Reference Forms No friend for family references will be accepted. All three must be professional with at least one coming from an instructor or supervisor. Reference forms must be submitted in a sealed envelope with the signature of the referee on the back flap. Resume Statement of Purpose Applicants can use the page provided in the application or can attach a type written statement. Basic Statistics course completed with a C or better CSU, Bakersfield requires that all students have immunization records on file verifying proof of MMR (Measles, Mumps, Rubella) vaccination. Please provide a copy of your MMR vaccination with your application or contact the Health Center ( ) to discuss your options to meet this requirement. This requirement will not prevent you from being admitted, but it will block you from registering for courses. Submit all application materials to: CSUB EXTENDED UNIVERSITY 9001 Stockdale Highway 30BDC Bakersfield, CA ATTN: Admissions/Academic Advisor Admission to the Extended University degree program does not constitute admission to the CSUB Main Campus degree program. Students planning to attend classes on the Main CSUB campus should contact the Extended University Degree Program Admissions/Academic Advisor for more information. If you have any questions regarding this application, need information concerning the program or program criteria, please feel free to contact us at NONDISCRIMINATION POLICY EUD does not discriminate on the basis of race, color, national origin, sex, physical handicap, or sexual orientation in the educational programs or activities it conducts. Students admitted with physical, perceptual or learning disabilities will be given necessary accommodations provided that their disability has been verified by the CSUB Office of Services for students with Disabilities ( ).

2 PART PART A1 A This is an application for: Fall Winter Spring Summer FOR OFFICE USE ONLY CHECK/M.O. #: AMOUNT: DATE RECEIVED: Specify major/program objective: Option, emphasis or concentration (if any): Legal name: Other name(s) that may appear on your academic records: Birthdate: Sex: Male Female Social Security Number: CSUB ID# (if applicable): Current mailing address: Permanent address if different from current address: Phone Number: Fax Number: Alt. Phone Number: FOR OFFICE USE ONLY TRANSCRIPTS GWAR REFERENCES RESUME STATEMENT OF PURPOSE OVERALL GPA: LAST 90 GPA: DEGREE: STATS: ACCEPTED DENIED

3 PART PART A2 A Country of Citizenship (all must answer): Use the options listed below to provide your citizenship code: Y US Citizen R Refugee/Asylum F F Visa (student) J J Visa N None of the above I Immigrant I-551 ( green card ) Date issued: (be prepared to submit verification) O Other visa (specify): Date issued: If you were born outside the US, what year did you move to the US? Use the options listed below to provide your ethnic identity code: 1 American Indian or Alaskan Native; tribe: 2 Black, non-hispanic, including African American 3 Mexican American, Mexican, Chicano 4 Other Latino, Spanish- origin, Hispanic 5 Other Asian 6 Other Pacific Islander 7 White 8 Other 9 No Response A Central American B South American C Chinese D Decline to State F Filipino G Guamanian H Hawaiian J Japanese K Korean L Laotian M Cambodian N Samoan P Puerto Rican Q Cuban R Asian Indian S Other Southeast Asian T Thai V Vietnamese List your California County of residence, other US State or Country: Are you a Veteran? Yes No Print the names and locations of all colleges and universities attended. Begin with the last institution attended. Attach a separate sheet if you need more space. Enrolled: Degree Awarded: School Name State From To AA/AS/BA/BS/etc. Are you eligible to re-enroll at all institutions previously attended? Yes No (if not, please attach explanation)

4 PART PART A3 A CERTIFICATION to be read and signed by all applicants to certify the accuracy of the information provided. I certify under penalty of perjury under the laws of the State of California and the United States that I have provided complete and accurate responses to the items on this application. I further certify that all official documents submitted in support of this application are authentic and unaltered records that pertain to me. I authorize the California State University to release any information submitted by me in connection with my application to any person, firm, corporation, association, or government agency to verify or explain the information I have provided, to obtain other records necessary for my application, or in connection with perjury proceedings. My signature certifies the accuracy and completeness of the information provided. I understand that any misrepresentation may be cause for denial or cancellation of admission or enrollment. I certify that so long as I am a student at this institution, I will advise the residence clerk if there is a change in any of the fact affecting my residence. City and County Applicant s Signature Date You are required to include your social security number (or taxpayer identification number) on admission application forms to all CSU campuses pursuant to Section 41201, Title 5, Code of California Regulations and Section 6109 of the Internal Revenue Code. CSU campuses use the social security number to identify your student records maintained in your association with the campus and, if needed, to help collect debts owed the university. Your social security number may be written on your application fee check to facilitate the processing of your fee payment. Also, the Internal Revenue Service requires the university to file information returns that include the student s social security number and other information such as the amount paid for qualified tuition, related expenses, and interest on educational loans. That information is used to help determine whether you, or a person claiming you as a dependent, may take a credit or deduction to reduce federal income taxes. If you do not have a social security number at the time you file the application, you may leave the item blank and the campus will assign a temporary number. However, you are required to obtain a social security number and submit it to the university by the time you begin enrollment. Failure to furnish your correct social security number may result in the imposition of a penalty by the Internal Revenue Service.

5 PART PART B1 A Completion of Part B is required; the information provided below should support the information provided on PART A. How did you hear about us? CSUB Website Google/Online Search TV or Radio Social Media Word of Mouth Other: Specify major/program objective: Social Security Number: CSUB ID# (if applicable): Legal name: Current mailing address: Phone Number: Fax Number: Alt. Phone Number: Birthdate: Sex: Male Female Ethnic Identity code as stated in Part A, page 2: List below the three faculty members who best know your academic qualifications, including performance, potential, and motivation. Name Address Position and Institution

6 STATEMENT OF PURPOSE PART PART B2 A Write a brief statement of purpose describing reason(s) for pursuing graduate or postbaccalaureate study. Include any additional information concerning your preparation which is pertinent to the objective specified. You may use the page provided or attach a type-written statement. I certify that the information submitted in this application is true, complete and accurate. I understand that any misrepresentation will be cause for denial of admission. Signature: Date:

7 California State University, Bakersfield EXTENDED UNIVERSITY DEGREE PROGRAMS 9001 Stockdale Highway 30BDC Bakersfield, California Phone Fax MSA GRADUATE REFERENCE FORM Applicant: Please complete this section, then deliver or mail this form and self-addressed envelope to your referee. Ask your referee to return the letter to you in the attached envelope with his/her signature across the seal. Do not open the envelope or break the seal. Submit sealed envelope with your application. Name: CSUB ID or SSN: Phone: I understand that this recommendation will be used only for admission and fellowship decisions, and I hereby waive my right of access to this recommendation. Signed Date Respondent: The admissions committee would appreciate your judicious evaluation of the applicant. CSU Bakersfield/Extended University Division uses a self-managed application. To preserve the confidentiality of this recommendation, please affix your signature across the sealed flap of the envelope and return it to the applicant who will submit it with his/her application packet to the CSUB Extended University Admissions Office. If you do not know the student well enough to give a recommendation, please initial here:. ALL REFERENCE FORMS MUST BE PROFESSIONAL (I.E. SUPERVISOR, INSTRUCTOR, ETC.) Name of Respondent: Phone: Position/Title: Organization: How long have you known the applicant? In what capacity? PLEASE RATE THE APPLICANT ON THE QUALITIES LISTED BELOW: Truly Exceptional (top 5%) Outstanding (top 15%) Above Average (top 25%) Average (mid 50%) Below Average (lowest 25%) Overall Intellectual Ability Motivation Analytical Ability Ability to work well with others Ability in oral expression Ability in written expression Creativity Self-Confidence Leadership I strongly recommend, recommend, recommend with reservations this applicant for the MSA Program. I do not recommend this applicant for the MSA program. I would be willing would not be willing to respond to additional questions by phone. Signed Date NONDISCRIMINATION POLICY EUD does not discriminate on the basis of race, color, national origin, sex, physical handicap, or sexual orientation in the educational programs or activities it conducts. Students admitted with physical, perceptual or learning disabilities will be given necessary accommodations provided that their disability has been verified by the CSUB Office of Services for students with Disabilities ( ).

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