APPLICATION FOR ADMISSION

Transcription

1 CHEYNEY OF PENNSYLVANIA SCHOOL OF EDUCATION AND PROFESSIONAL STUDIES APPLICATION FOR ADMISSION DEGREE AND PROGRAM (CHECK ALL THAT APPLY) Call Me MISTER Undergraduate Program TS 2 Project Undergraduate Program Call Me MISTER Graduate Masters Program Call Me MISTER Scholar BACHELORS DEGREE Call Me MISTER Institute Member MASTERS DEGREE PERSONAL INFORMATION TITLE: Mr. Ms. GENDER FEMALE MALE FIRST RESIDENCY STATUS MIDDLE PRIMARY CITIZENSHIP LAST SECONDARY CITIZENSHIP SUFFIX VISA NEEDED YES NO NICK HISPANIC OR LATINO ALTERNATIVE African America/Black American Indian/Alaska Native DATE OF BIRTH Asian Native Hawaiian/Other Pacific Islander White CONTACT INFORMATION MAILING ADDRESS PERMANENT ADDRESS CITY CITY COUNTRY COUNTRY ZIP/POSTAL CODE ZIP/POSTAL CODE ADDRESS CELL/MOBILE HOME PHONE OFFICE PHONE

2 STANDARDIZED TEST SCORES PRAXIS I READ PRAXIS II CONTENT KNOWLEDGE WRITING CURRICULUM, INSTRUCTION & ASSESSMENT SAT ACT READING ENGLISH READING WRITING WRTING SCIENCE GRE GRE VERBAL VERBAL QUANTITATIVE QUANTITATIVE % QUANTITATIVE QUANTITATIVE % QUALITATIVE QUALITATIVE % QUALITATIVE QUALITATIVE % ANALYTICAL ANALYTICAL % ANALYTICAL ANALYTICAL % ACADEMIC INFORMATION GRADES ARE A TRUE MEASURE OF ABILITY YES NO WITHDRAWN, OR REPEATED A TERM IN ANY INSTITUTION (IF YES, EXPLAIN) YES NO DISMISSED, OR DENIED READMISION TO, ANY INSTITUTION (IF YES, EXPLAIN) YES NO TRANSERFERRED FROM ONE INSTITUTION TO AN (IF YES, EXPLAIN) YES NO INTERRUPTIONS IN COURSE OF STUDY (IF YES, EXPLAIN) YES NO

3 EDUCATION HIGH SCHOOL OR PRE-COLLEGE INSTITUTION CITY GRADUATE DATE GPA HIGH SCHOOL OR PRE-COLLEGE INSTITUTION CITY GRADUATE DATE GPA

4 ACADEMIC EXPERIENCE DISTINCTIONS, HONORS, AND AWARDS TEACHING, MENTORING, AND EDUCATIONAL LEADERSHIP EXPERIENCE RESEARCH AND INTERNSHIP EXPERIENCE EXTRACIRRICULAR/VOLUNTEER ACTIVITIES START DATE END DATE DESCRIPTION CURRENTLY ACTIVE YES NO START DATE END DATE DESCRIPTION CURRENTLY ACTIVE YES NO START DATE END DATE DESCRIPTION CURRENTLY ACTIVE YES NO

5 RECOMMENDATIONS RECOMMENDER 1 TYPE WAIVED RIGHT FIRST TITLE LAST RECCOMENDER 2 TYPE WAIVED RIGHT FIRST TITLE LAST STATEMENT OF INTEGRITY AFTER YOU READ, COPY AND SIGN WHERE DESIGNATED I hereby certify that the information presented in my application is accurate, complete and honestly presented. I also certify that any information submitted on my behalf, including letters of recommendation, Is authentic. I authorize all persons and entities herein named to provide information to the Call Me MISTER program of Cheyney University of Pennsylvania or its agent to verify any aspect of my application and/or my credentials for admission. I understand and agree that any inaccurate information, misleading information, or omission will be cause for the recision of any offer of admission or for discipline, dismissal or revocation of degree if discovered at a later date. This application is my own, honest statement. SIGNATURE DATE