Lincoln Memorial University-Department of Social Sciences Graduate Program Interest Questionnaire For 2014 admissions cycle Specify Program of Interest: Master of Science in Criminal Justice (MSCJ) Master of Public Administration (MPA) Please enter your information in each of the following sections. Fields with a red asterisk (!) are. Personal Information Last Name! First Name! Middle Name Preferred Name! Last four of Social Security Number Gender! (####) Date of Birth! (mm/dd/yyyy) E-mail Address Enter a valid E-mail Mailing Address! Address Check if address is outside of U.S. or Canada Address (cont) City State/Province Zip/Postal Code 1
Contact Information Home Phone Cell Phone (###-###-####) (###-###-####) Have you gone by any other names, nicknames, or maiden names that you may have used on previous academic, employment, or other records? Please Select: Yes No If Yes, list any other names you may have used on previous academic, employment, or other records. Last Name 1 First Name 1 Last Name 2 First Name 2 Are you a U.S. Citizen? Yes No If no, please enter citizenship: Additional Information This information is voluntary. It will be used in a nondiscriminatory manner consistent with applicable civil rights laws. Race: (Choose all that apply) American Indian or Alaska Native Black or African American Hispanic/Latino White/Caucasian Asian Native Hawaiian or Other Pacific Islander Non-Hispanic/Latino Other Race/Ethnicity Are you a Veteran of the U.S. Military Service? Veteran? Yes No If yes, did you receive an honorable discharge? Yes No If you answered no, please explain: 2
English Language Proficiency Is English your native language? Yes No If you checked No, you are required to submit an official report of your TOEFL score. Please use code 1408 Lincoln Memorial University Unofficial Test of English as Foreign Language (TOEFL) Scores. Please specify if your TOEFL test was taken as a paper-based, computer-based, or internet-based format. Exam Date Format Unofficial Score Family Information Have any of your relatives attended LMU?! Yes No How do you plan to finance your graduate education? (Check all that apply) * Loans Personal/Family Funds Military Scholarship Other Scholarship Other (please specify): Academic Information Did you graduate High School? Yes No High School Information Year Graduated! Name of School 3
Colleges Attended College 1 Years Attended! Name of College Hours Earned College 2 Years Attended! Name of College Hours Earned College 3 Years Attended! Name of College Hours Earned College 4 Years Attended! Name of College Hours Earned College 5 Years Attended! Name of College Hours Earned 4
Honors and Awards Name of Award Award Date Institution Conferring Award Prerequisite Coursework! Please list the number of credit hours of relevant undergraduate coursework that prepares you for the graduate degree program. If you have not yet taken a course, please list the date you plan to take it. Course Credit Hours Course Credit Hours Course American National Economics Political Theory Government Comparative Politics Ethics Public Policy Credit Hours Computer Literacy History Psychology Constitutional Law International Politics Social Science Research Methods Corrections Investigations State and Local Government Courts Leadership and Statistics Administration Criminal Law Juvenile Justice Sociology Criminal Procedure Policing Social Work Criminological Theory Politics and Law Victimology Other (specify): Other: Other: Other: Other: Other: 5
Experiences Please describe your professional, academic, and volunteer experiences that are relevant to your desire to attend a graduate program at Lincoln Memorial University. Related Experience 1 Position Description Experience Type (e.g. professional, research, volunteer) Date of Experience: Start End Name of Organization: Name of Contact: City, State Contact Phone Number Average number of hours/week Total number of hours over span of experience Description of Duties: (Please limit text to 480 characters. Please note this includes spaces) Related Experience 2 Position Description Experience Type Date of Experience: Start End Name of Organization: Name of Contact: City, State Contact Phone Number Description of Duties: (Please limit text to 480 characters. Please note this includes spaces) 6
Related Experience 3 Position Description Experience Type Date of Experience: Start End Name Organization: Name of Contact: City, State Contact Phone Number Description of Duties: (Please limit text to 480 characters. Please note this includes spaces) Related Experience 4 Position Description Experience Type Date of Experience: Start End Name of Organization: Name of Contact: City, State Contact Phone Number Description of Duties: (Please limit text to 480 characters. Please note this includes spaces) 7
Clubs and Organizations Please list any memberships you have in school, social, or professional organizations or clubs. Include information about any offices held. Name of Organization Office(s) Held Type (e.g. academic or professional) Years of Membership Source of Referral How did you hear about Lincoln Memorial University s MSCJ of MPA program? * Academic advisor LMU Outreach Professional Organization Internet LMU faculty or staff Media (TV, Radio, Print) Recruitment Mailing Other Right to privacy and access to confidential references Under the Family Educational Privacy Rights Act, 20 U.S.C. 1232(g), you may, but are not required to, waive your right of access to confidential references given for any of the purposes listed on this form. If you waive your right to access, the waiver remains valid indefinitely. Check the appropriate box below: I DO NOT waive my right to keep my information private I waive my right to keep my information private You may only release my information to the following (provide name and relationship to applicant): 8
Personal References The MCJ and MPA programs require at least three (3) letters of recommendation from academic and/or professional references. Please list the names of individuals who will submit a recommendation on your behalf. At least two (2) of these references must be provided by a current or former college faculty member who can attest to your academic qualifications. Reference 1:! Name Title or Rank Date Requested Telephone E-mail address Reference 2:! Name Title or Rank Date Requested Telephone E-mail address Reference 3:! Name Title or Rank Date Requested Telephone E-mail address Reference 4: Name Title or Rank Date Requested Telephone E-mail address 9
Personal Statement! In the space below please enter your personal statement. Your statement is limited to 750 words or 5000 characters including spaces. Our recommendation for the personal statement is as follows: 1. Why do you want to pursue a graduate degree? Describe how your past experiences have helped to shape your academic and professional interests. Demonstrate a passion for the subject matter and how a MSCJ or MPA degree will help you achieve those goals. What are topics of interest to you? What do you hope to gain during your graduate studies? Be sincere and specific in your response. 2. How have you prepared yourself to successfully complete graduate school? Discuss the experiences (working, volunteering, internships, etc.) that have shaped your views and led you to apply to graduate school. Talk about specific skills you have acquired and how they will help you to reach the goals you laid out for yourself. 3. Why are you applying to a graduate program at LMU? Demonstrate to the admissions committee that you have done your research and have specific reasons why you desire to attend the MSCJ or MPA program at LMU. 4. What makes you stand out from other applicants? Tell the committee how your experiences, skills, interests, or goals make you an exceptional candidate for admission to a graduate program. 10
Statement of Past or Pending Disciplinary Action Were you ever the recipient of any action (e.g. disciplinary, dismissal, disqualification, suspension, etc.) by any college or university for unacceptable academic performance or conduct violations (e.g. academic dishonesty, disruptive or threatening behavior towards other students, staff, or faculty)? Please Select: Yes No Have you ever pled no contest or nolo contendere, or been convicted of either a felony or misdemeanor, other than a minor traffic violation (e.g. speeding, parking, running a stop sign)? Please Select: Yes No If you answered No to either of the above, please provide a full explanation: Discrimination Clause Lincoln Memorial University admits students of any race, sex, handicap, religion, nationality, and ethnic origin to all rights, privileges, programs, and activities generally accorded or made available to its students. It does not discriminate on basis of race, sex, sexual, orientation, handicap, religion, national or ethnic origin in administration of its educational policies, admissions policies, scholarships and loan programs, or athletic and other collegeadministered programs. Certification and Signature I certify that all information provided is true, accurate, complete, and correct to the best of my knowledge and belief, and is made in good faith. I know and understand that any and all items contained herein are subject to verification and I consent to the full release of all information concerning my capacity and fitness for the educational program by employers, educational institutions, and other agencies. I agree that providing inaccurate or false information or that failure to comply with University policy may result in disciplinary action, including dismissal. Finally, I authorize the people named in my LMU Graduate Program Interest Questionnaire to provide an evaluation about my academic performance and/or nonacademic experience relative to my potential for becoming a successful graduate student. Do you certify? Yes No The electronic signature consists simply of your name, typed by you on your keyboard. The signature is your confirmation that the information you have filled out is your own work and the information is factually true. Once you type in your name and the date, this will count as your electronic signature. Signature Full Legal Name Signature Date (mm/dd/yyyy) 11