1. Last Name First Name Middle or Maiden Name

2. Present Address:

Street: City: State: Zip:

3. Permanent Address:

Street: City: State: Zip:

4. Home Phone #: Area Code Number (numbers only)   

5. Office Phone #: Area Code Number (numbers only) 

6. Email Address: 

7. Birth Date : 2 Digit Month 2 Digit Day 4 digit Year

8. Gender: Female Male

9. Are you a permanent US citizen? Yes No

If you are not a US citizen what is your country of citizenship:  

If No, are you a permanent resident alien of the United States?  Yes No

If No, what is your immigration status in the U. S.

(Note:  You must submit a copy of your resident alien card with your application.)

10. Are you a legal resident of South Carolina?           Yes Uncertain No                    Are you a legal resident of Georgia?         No Yes Uncertain

List the city, county and state where you have lived for the past five years (list up to the last three residences for the past five years):

City, Cnty, ST: Dates (year to year)

City, Cnty, ST: Dates (year to year)

City, Cnty, ST: Dates (year to year)

11. USC Aiken is required to collect information on the ethnic and racial composition of its student body and report this information to the U.S. Department of Education.

    11. a.)  Do you consider yourself to be either Hispanic, Latina or of Spanish origin?   No Yes

    11. b.) Please select "Yes" to any of the following groups with which you identify:

                                American Indian or Alaskan Native        No Yes

                                Asian                                               No Yes                   

                                 Black or African American                    No Yes

                                Native Hawaiian or Pacific Islander        No Yes

                                White                                                    No Yes

12. Next of Kin:

Name:   Phone Number: Area Code Number (numbers only) 

Address: Street: City: State: Zip:

13. Intended Field of Study: M.Ed. in Elementary Education M.Ed. in Educational Technology M.S. in Applied Clinical Psychology

14. Term Applying For? Spring Summer I Summer II Year Applying For? 2013

15. Have you enrolled for GRADUATE credit at USC prior to this date? No Yes

    15. a.)Name on these records if different from that on line 2: 

16. Have you enrolled for GRADUATE credit at any other non-USC institution prior to this date? No Yes

17. List in chronological order all colleges and universities you have attended, including any work done at USCA. Official transcript(s) of academic work at each college attended (except coursework in the USC System) must be sent by that Registrar directly to the USCA Graduate Office.

Type in the college or university, the dates of attendance (from and to), the degree earned and date, and the major:

A.

B.

C.

D.

E.

18. The required entrance exam I have taken is: GRE MAT No exam taken yet  

(Official test scores must be sent to the USCA Graduate Office)

If I have not yet taken the entrance exam, I will take the required entrance exam for my major (i.e. GRE, MAT) on:

19. List the names of persons whom you have requested to send recommendations:

A.