Application for Graduate Admission

Graduate College 1507 N Boulder Ave, Tomlinson 113 Russellville, AR 72801-2222 (479) 968-0398 Fax (479) 964-0542 http://graduate.atu.edu
Please Print 1.) Social Security Number ______/______/______ 2.) Legal Name Last__________________________ First____________________ Middle________________ T Number _________________________________
(If Applicable)

3.) Other names used on academic records (if any) _________________________

4.) Permanent Home Address Street or Route and Box________________________________ City ________________________State _____________Zip_________ County _______________________Telephone Number (____)_____________ How long have you lived at the permanent address?________ If six months or less, list former address for the past six months and how long you lived at each _____________________________________________ 5.) Local Address (if different than permanent address) Street or Route and Box ________________________ City_________________ State ___________Zip_______ Telephone Number (____)__________________ 6.) Emergency Contact Name Last__________________________ First_______________________ Relationship___________________ 7.) Emergency Contact Address (if different than permanent address) Street or Route and Box_________________________ City ________________________State __________ Zip_________ Telephone Number (___)________________ 8.) E-Mail address__________________________________________________________________________ 9.) Date of birth Month_______ Day_______ Year________ 10.) Sex* Male________ Female________ 11.) Ethnic Origin* (Requested for reporting purposes only and will not be used to determine admission status) 1. ____African American, Non Hispanic 2. ____Native American/Alaskan Native 3. ____Asian American/Pacific Islander 4. ____Mexican American/Latin American/Hispanic 5. ____Caucasian 6. ____Non-Resident Alien 12.) ____U.S. Citizen ____Non-Resident Alien ____ Country of Citizenship ____Visa Type ____Expiration Date _______________Card Number _____________Date Issued *Voluntary information to be used in nondiscriminatory manner consistent with civil rights laws for reporting statistical purposes only and cannot affect your eligibility for admission. 13.) Are you a legal Arkansas resident? _____Yes _____ No To be classified as an Arkansas resident for University fee purposes, a student must have established a bona fide domicile in this state and resided in the domiciliary status for at least six (6) consecutive months prior to the beginning of the semester for which fees are to be paid. Contact the Office of Graduate College for additional information. All Arkansas counties, as well as, all contiguous states are considered in-state for tuition purposes. Students who need to request accommodations made available through the Americans with Disabilities Act should contact the Affirmative Action Office at (479) 964-3230.

14.)

Have you ever enrolled for college courses, either as a full-time student, or a professional workshop? Yes ___No ___
If yes, list all the colleges where you have been enrolled, even if you did not complete a full term or receive a grade report. (Failure to list all colleges is considered falsification or records and may result in cancellation of a students admission.) Attach additional sheets if necessary. Request each institution (other than Arkansas Tech University) to send an official transcript to the Office of Graduate College.

UNDERGRADUATE Name of College or University

City and State

Dates Attended

Dates Conferred

Degrees/Major

GRADUATE Name of College or University

City and State

Dates Attended

Dates Conferred

Degrees/Major

15.) 16.)

Semester for which you are applying for: Fall____ Spring____ Summer I____ Summer II____ of 20____ Types of Admission (please read carefully) _____Non-Degree Seeking _____Transient Seeking to complete coursework toward degree or certificate completion at transfer institution. _____Degree Seeking Applicants who plan to pursue a masters degree at Arkansas Tech University must furnish OFFICIAL transcripts from EACH college/university attended. Indicate degree and area of specialization:
Master of Education Master of Engineering ____Elementary Education ____Electrical Engineering option Secondary Education ____ Mechanical Engineering option ____ English ____ Nuclear Engineering option ____ Physical Education ____ Instructional Technology Instructional Design & Technology option ____ Instructional Technology Library Media option ____ Instructional Improvement ____ Educational Leadership ____ School Counseling and Leadership ____ Teaching, Learning, and Leadership Curriculum Administrator option ____ Teaching, Learning, and Leadership Non-Traditional Teacher Leader option Educational Specialist ____Educational Leadership Master of Science ____ Fisheries and Wildlife Biology ____ Information Technology IT option ____ Information Technology IS option ____ College Student Personnel ____ Psychology ____ Emergency Management and Homeland Security ____ Health Informatics Master of Science Nursing ____Administration Master of Liberal Arts ____Communications ____The Fine Arts ____ Social Sciences

Master of Arts ____English ____ English with TESL ____ History ____Multi-Media Journalism ____Spanish ____TESOL ____ Teaching

17.)

Are you registered with the Selective Service? Yes_____ No_____ If no, are you (check one): ____ Female ____In the armed forces on active duty (members of the Reserves or National Guard are not considered active duty) ____Under the age of 18 ____Born before 1960 ____A permanent resident of the Trust Territory of the Pacific Islands or the North Mariana Islands ____An alien lawfully admitted to the United States as a non-immigrant Have you ever been convicted of a felony? Yes____ No____ (If yes, attach a separate sheet of paper explaining the circumstances) How did you hear about the Arkansas Tech University graduate program? From alumni____ From friend____ Former ATU student____ ATU Homepage____ Other____________________________ I hereby affirm that all information supplied in these blanks is complete and accurate. It is my understanding that I shall not be considered for admission to Arkansas Tech University until I have submitted all credentials specified. I understand that withholding information requested or giving false information may make me ineligible for admission and enrollment.

18.) 19.)

Applications Signature_______________________________________________________________Date_______________________________
Arkansas tech University does not discriminate on the basis on color, sex, race, age, national origin, religion, or disability in any of its practices polices, or procedures. This includes, but is not limited to, admission, employment, financial aid or educational services, Arkansas Tech University complies with all applicable state and federal laws including, but not limited to Title VI and Title VII of the Civil Rights Act of 1964 as amended, Title IX of the Educational Amendments of 1972, Section 504 of the Rehabilitation Act Amendments of 1974, the Civil Rights Restoration Act of 1987, the Americans With Disabilities Act of 1990, and the Civil Rights Act of 1991. Social security numbers are used as identification numbers for convenience and for consistency with our records. The Affirmation Action Office has been designated to coordinate compliance efforts.

Campus Safety Questions

Office of Graduate College Arkansas Tech University Tomlinson 113 Russellville, AR 72801-2222 479-968-0398 http://graduate.atu.edu Arkansas Tech University has amended the application for admission to include campus safety questions effective August 15, 2008. To be in compliance with the current policy, you must accurately complete and return this form. Neither admission nor registration will be allowed until your information has been received and evaluated.

Please print Legal Name

First_______________________Middle_________Last________________________T#__________________ Address Number and Street or Route and Box_______________________________City_____________________________State______________Zip__________ Phone Number (_____) _____________________ County________________Date of Birth _____/_____/_______ To maintain a safe learning community, we ask the following questions of all applicants. We cannot process your application unless you answer these questions. Answering yes to one or more of the following questions will not necessarily preclude you from being admitted. However, failure to provide complete, accurate, and truthful information will be grounds to deny or withdraw admission, or to dismiss after enrollment. 1. 2. 3. 4. Have you lived at your PERMANENT ADDRESS 6 months or longer? ___Yes ___No If no, please list your previous address and length of residency. _____________________________________________________ Are you a current undergraduate Arkansas Tech University student? ___Yes ___No Are you seeking licensure or certification only? ___Yes ___No Are you registered with Selective Service? ___Yes ___No If no, please tell us what category best describes you. Female ____ In the armed forces on active duty (members of the Reserve and National Guard are not considered active duty) ___ Under the age of 18 ___ Born before 1960 ___ A permanent resident of the Trust Territory of the Pacific Islands or the Northern Mariana Islands ___ An alien lawfully admitted to the United States as a nonimmigrant. ___ Have you ever been convicted of, or pleaded no contest to, a crime other than a minor traffic violation? ___Yes ___No Have you ever been expelled, dismissed, suspended, or placed on probation by any school (for non-academic reasons)? ___Yes ___No If yes, please give a brief explanation. _________________________________________________________ Do you have any criminal charges pending against you? ___Yes ___No If you have ever served in the military, did you receive any type of discharge other than an honorable discharge? ___Yes ___No Immunization records are not required for online students. Will you be taking online classes only? ___Yes ___No

5. 6. 7. 8. 9.

You must promptly notify the Graduate College of any criminal charge, any disposition of a criminal charge, or any school, college, or university disciplinary action against you, or any type of military discharge other than an honorable discharge that occurs at any time after you submit this document. I hereby affirm that all information supplied is complete and accurate. I understand that withholding information requested or giving false information may make me ineligible for admission and enrollment. Applicants Signture_________________________________________________________________Date______________________
Arkansas Tech University does not discriminate on the basis of color, sex, race, age, national origin, religion, or disability in any of its practices, policies, or procedures. This includes, but not limited to, admission, employment, financial aid or educational services. Arkansas tech University complies with all applicable state and federal laws including, but not limited to, Title VI and Title VII of the Civil Rights Act of 1964 as amended, Title IX of the Educational Amendments of 1972, Section 504 of the Rehabilitation Act Amendments of 1974, the Civil Rights Restoration Act of 1987, the Americans With Disabilities Act of 1990, and the Civil Rights of 1991. The Affirmative Action Office, Administration Building, Suite 200, has been designated to coordinate compliance efforts.