SCHOOL OF EDUCATION

APPLICATION FOR GRADUATE ADMISSION


All materials submitted in conjunction with an application become the property of Georgia Southwestern State University and will not be returned.


Admission requested for: (Please Check One) *
Fall (August)
Deadline: May 31
Summer (June)
Deadline: March 15
Year 20

APPLICANT INFORMATION

Full Legal Name First (given) * Middle Last *
Permanent Mailing Address Street Address * Apt No.
City * State * Zip *
County Telephone (including Area Code) * Email Address *
Indicate other names used on official
records if different from above:
First Middle Last

Contact in case of emergency Parent      Spouse      Guardian      Other
First Last Telephone (including Area Code)
Address Apt No.
City State Zip

CITIZENSHIP *

US Citizen Country of Citizenship (if not US) Visa Type
Non-Resident Alien
Resident Alien (copy of green card required)    

ARE YOU APPLYING FOR IN-STATE TUITION? *

Yes No

RESIDENCY STATUS *

Legal Resident of Georgia?
Yes  If yes, how long?   (Years) (Months)   County
No  If no, legal state of residency
Have you established and maintained legal residence in Georgia for at least 12 consecutive months immediately preceding the first day of classes for the term in which you plan to enroll?
Yes No
Have youe ever lived outside of the state of Georgia?
Yes No
If you have ever lived outside the state of Georgia and now live in Georgia, how long have you continuously lived in the state of Georgia at this time?
  (Years) (Months) 
Did you (or your parents if you are claimed as a dependant) file a state income tax return this past year?
Yes   No  If yes, in which state did you file?

In accordance with Board of Regents Policy 4.3.4, all applicants who are accepted for admission or readmission to Georgia Southwestern State University for Fall, 2011 or any academic semester thereafter, and who seek to be classified as in-state for tuition purposes, will be required to provide validation of residency and lawful presence in both the State of Georgia and the United States. Acceptance to Georgia Southwestern State University is conditional until lawful presence is verified.

MILITARY STATUS

What is your Military Status Coding?
Not Applicable
Military Active Air Force
Military Active Army
Military Active Coast Guard
Military Active Marine
Military Actice Navy
Military Veteran
Military National Guard
Military Reservist
Dep/Spouse Active Air Force
Dep/Spouse Active Army
Dep/Spouse Active Coast Guard
Dep/Spouse Active Marine
Dep/Spouse Active Navy
Dep/Spouse Veteran
Dep/Spouse National Guard
Dep/Spouse Reservist

BIOGRAPHIC INFORMATION

Birthdate * Gender Marital Status Ethnic Origin: Please answer the following two questions. (optional)

Place of Birth (City, State)
Female
Male
Single
Married
Divorced
Widowed
Separated

Are you Hispanic or Latino?
Yes No
What is your race? (Choose one or more.)
American Indian or Alaska Native
Asian
Black
Native Hawaiian or Pacific Islander
White

ACADEMIC INFORMATION *

Classification:  Regular Admission Classification:  Non-Degree Admission
Master of Education Post Baccalaureate (certification renewal, increase gpa, personal development, special projects, etc.)
Early Childhood Education Purpose:
Middle Grades Language Arts Transient
Middle Grades Mathematics  

List all colleges and universities you have attended or are attending, including Georgia Southwestern State University. Official transcripts are required from each institution. If you are currently enrolled, give the last expected date of enrollment.
Name of Institution Attendance From (mm/yy) Attendance To (mm/yy) Degree Earned (mm/yy)

I understand that any material false statement made knowingly and willfully by me on this application, or any documents attached hereto may, in accordance with O.C.G.A. 16-10-71, which provides that upon conviction, a person who knowingly commits the offense of false swearing shall be punished by a fine of not more than $1000 or by imprisonment for not less than one nor more than five years, or both, subject me to prosecution in a court of law. Additionally, I further understand that any such false statement may subject me to immediate dismissal from the institution. Further, I certify that, to the best of my knowledge, the information submitted on this application is true and complete.
Yes, I agree No, I do not agree. Do not process my application. Date: 
Signature ______________________________________________