Mount Saint Mary College GRADUATE PROGRAM ADMISSION APPLICATION

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1 GRADUATE PROGRAM ADMISSION APPLICATION CHECK DESIRED PROGRAM Business (MBA) Childhood Ed (1-6) Adolescence Ed (7-12) Adolescence & Literacy Adolescence & Special Ed Special Ed (1-6) Special Ed (7-12) Literacy (birth-grade 6) Literacy (5-12) Literacy (birth-grade 6) & Literacy (grades 5-12) Literacy (birth-grade 6) & Special Ed (grades 1-6) Literacy (grades 5-12) & Special Ed (grades 7-12) Childhood & Special Ed Childhood Ed & Literacy Extension Program (5-6) Extension Program (7-9) Nurse Practitioner-Adult Health (ANP) Nurse Practitioner-Family Health (FNP) Certificate in Family Nurse Practitioner (FNP) Certificate in Adult Health Nurse Practitioner (ANP) PERSONAL DATA (Please PRINT or TYPE) Social Security No.: (or student number) Name: Birth Date Last (Maiden) First MI Mailing Address Home Ph. Business Ph. Cell Ph. Address: Gender: Male Female Veteran: Yes No Religion: Race: American Indian Asian Black Hispanic Pacific Islands White U.S. citizen: Yes No If No, country: Visa Type: Number: Date: Have you ever attended Mount Saint Mary College? If so, when: ENROLLMENT INFORMATION STUDY TO BEGIN: Fall Spring Summer Other STATUS: Degree Seeking Certificate Seeking Limited Coursework Full-time Part-time Visitor

2 APPLICATION REQUIREMENTS Graduate Admissions can only process completed applications. It is the responsibility of the applicant to meet the following requirements: OFFICIAL LETTERS OF GRADUATE PROGRAM TRANSCRIPTS GRADUATE EXAM RECOMMENDATION INTERVIEW OBJECTIVE MBA Required If Requested 3 required Required Required MS Ed Required Not Required 3 required Required Required MS Nur Required Not Required 3 required Required Required For further information, please contact the Office of Graduate Admissions at EDUCATION Regardless of the length of attendance, list in chronological order, ALL collegiate institutions attended. Attach additional sheets if needed. An original transcript, for each school attended, must be sent to the college. UNDERGRADUATE/GRADUATE DEGREE AWARDED, COLLEGE OR UNIVERSITY CITY AND STATE DATES ATTENDED DATE OF DEGREE, OR CREDITS HONORS AND ACTIVITIES Please list any community, extracurricular or professional activities. EMPLOYMENT RECORD Attach additional sheets if needed or resumé. TYPE OF WORK NAME AND ADDRESS OF EMPLOYER OR EXPERIENCE TITLE OR POSITION DATES OF EMPLOYMENT

3 GRADUATE PROGRAM ADMISSION APPLICATION REFERENCES Please list the names of three individuals who will submit letters of recommendation. It is the responsibility of the applicant to forward recommendation forms to the individuals listed below: NAME TITLE CERTIFICATE INFORMATION GRADUATE EDUCATION Do you now hold (or expect to hold upon admission) a valid Teaching Certificate in the United States? Yes No If yes: New York State Other state Teaching certificate title: GRADUATE NURSING RN License No. State Current Registration Until (date) ADDITIONAL INFORMATION: How did you learn about Mount Saint Mary College s graduate programs? Career planning/placement center Employer Friend or colleague Newspaper please specify Open house Television please Sspecify Graduate fair Radio please specify Graduate school guide Other please specify Please send official, undergraduate transcript(s), copies of examination results, copies of certificates (where applicable) and this completed form to: Office of Graduate Admissions 330 Powell Avenue Newburgh, NY 12550

4 GRADUATE PROGRAM ADMISSION APPLICATION GRADUATE STUDY OBJECTIVE Write about your current position and responsibilities, employment history, special interests and reason(s) for undertaking graduate work. I certify that the information provided in this application is true and complete to the best of my knowledge. Date Applicant s Signature Mount Saint Mary College does not discriminate in the admissions process on the basis of race, creed, national origin, age, disability, gender or marital status of the candidate for entrance. The college will make efforts to accommodate persons with disabilities in the majors of their choice. Persons with disabilities desiring accommodation are responsible for making their needs known to the Coordinator of Services for Persons with Disabilities. Information concerning this policy may be found in the Mount Saint Mary College Student Handbook or obtained from the Coordinator of Services for Persons with Disabilities.

5 GRADUATE PROGRAM RECOMMENDATION NOTE TO APPLICANT Please type or print your name and address, check off the program to which you are applying and your Review Option, and give this form to one of the three people whom you have asked to submit a recommendation for you. Applicant s Name Address CHECK DESIRED PROGRAM Business (MBA) Business (MBA)-Accounting Childhood Ed (1-6) Adolescence Ed (7-12) Adolescence & Literacy Adolescence & Special Ed Special Ed (1-6) Special Ed (7-12) Literacy (birth-grade 6) Literacy (5-12) Literacy (birth-grade 6) & Literacy (grades 5-12) Literacy (birth-grade 6) & Special Ed (grades 1-6) Literacy (grades 5-12) & Special Ed (grades 7-12) Childhood & Special Ed Childhood Ed & Literacy Extension Program (5-6) Extension Program (7-9) Nurse Practitioner-Adult Health (ANP) Nurse Practitioner-Family Health (FNP) Certificate in Family Nurse Practitioner (FNP) Certificate in Adult Health Nurse Practitioner (ANP) REVIEW OPTION The Family Educational Rights and Privacy Act of 1974 provides that the student have the option to review this recommendation or maintain its confidentiality by relinquishing the option to review. Please check your option: I wish to review this recommendation. I waive my right to review this recommendation. Signature NOTE TO RECOMMENDER The person whose name appears above has applied for admission to the Graduate Program specified above. We would appreciate your commenting on the applicant s academic and/or professional qualifications by supplying the following information in as much detail as possible. Please mail your recommendation directly to the appropriate division: Office of Graduate Admissions 330 Powell Avenue Newburgh, N.Y How long and in what capacity have you known the applicant? 2. What do you consider the applicant s most outstanding strengths or characteristics?

6 3. What are the applicant s chief weaknesses? 4. In your opinion, how well has the applicant considered, and prepared for, the decision to enter their graduate program? 5. Please rate the applicant in terms of the following criteria. OUTSTANDING ABOVE AVERAGE AVERAGE BELOW AVERAGE Academic Performance Verbal Communication Written Communication Breadth of General Knowledge Intelligence Motivation Maturity Independence Ability to initiate ideas and actions Capacity for planning EDUCATION ONLY Ability to work effectively with children NURSING ONLY Clinical knowledge and skills 6. Please indicate the degree to which you recommend the applicant for graduate study: Strongly recommend Recommend Recommend with reservations Do not recommend 7. Any other comments you care to make would be appreciated (use an additional sheet of paper if necessary). NAME OF RECOMMENDER Title Address Phone Signature Date

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