MDIV or MATS/Master of Social Work Application

Program of Application: *

First Name *

MI

Last Name *

Preferred Name

Street Address *

City *

State *

Zip *

Phone (Home)

Phone (Work)

Phone (Cell) *

Samford ID # *

Preferred Phone Number *

Home

Work

Cell

Primary Email Address *

Secondary Email Address

Do you have any materials under another name? *

Yes

No

If yes, please specify other name used:

Birth Date * +

Ethnicity *

Gender *

Female

Male

Personal Information - Citizenship Status

Citizenship Status *

U.S. Citizen

U.S. Permanent Resident

Other

Country/Territory of Citizenship *

Do you hold a VISA? *

Yes

No

Is this VISA current and valid?

Yes

No

If yes, Type of VISA:

Date VISA was issued (MM/DD/YYYY):

City of VISA issue:

VISA Number:

Does this VISA permit you to work?

Yes

No

Are you a Veteran? *

Yes

No

Still Serving

Background Information

Has disciplinary action, in writing, of any sort ever been taken against you by a supervisor, educational or training institution, health care institution, professional association, or licensing/certification board? *

Yes

No

If yes, please explain:

0/500 words

Are there any complaints currently pending against you before any of the above bodies? *

Yes

No

If yes, please explain:

0/500 words

Has there ever been a decision in a civil suit rendered against you relative to your professional work, or is any such action pending? *

Yes

No

If yes, please explain:

0/500 words

Have you ever been put on probation, suspended, terminated, or asked to resign by a graduate or internship program, practicum site, or employer? *

Yes

No

If yes, please explain:

0/500 words

Have you ever been convicted of a felony? *

Yes

No

If yes, please explain:

0/500 words

Have you ever been convicted of a misdemeanor? *

Yes

No

If yes, please explain:

0/500 words

Degree Information

Undergraduate Degree Received: *

Universities and Colleges attended *

Degree Status: *

Degree Planned

Degree Awarded

Date Degree Earned or Anticipated Date *

Resume and Personal Statement - Please include Honors, Awards, Sports & Extracurricular Activities, Certifications, Work Experience and Volunteer Experience in your resume and upload one document.

Resume:

Personal Statement:

The content of your personal statement must be your original writing which is solely authored by you. Plagiarism of any kind is not acceptable. Please develop your personal statement in a separate document and attach. Please address the following items in your personal statement.

a. Why do you want to enter your chosen profession?
b. Discuss experiences that have helped to prepare you for your career.
c. What are your short-term and long-term goals?
d. What are your strengths and weaknesses or areas needing improvement?
e. What other information do you consider important for the selection decision?

Application Certification

What influenced you most to apply to Samford University?

0/500 characters

I certify that all the information and statements I have provided in this application are correct and complete. I certify that the personal statement(s) submitted with this application is/are my original works. I further certify that all information submitted on my behalf, including letters of recommendation, is authentic. I understand that it is my obligation to provide true and complete answers to all questions. *

I agree.

I understand that withholding pertinent information or giving false information on this application will be cause for denial of admission to the Samford University College of Health Sciences, withdrawal of any offer of admission, cancellation of registration, expulsion from the program, or revocation of my degree. I understand that I have an ongoing obligation to inform the Enrollment Management Office in the College of Health Sciences of any changed circumstances within 30 days of my first notice of such events. *

I agree.

I realize that the institution reserves the right to withdraw an offer of admission if I fail to maintain satisfactory scholastic standing for work in progress or if final records fail to show completion of courses and/or degree required for admission. *

I agree.

Applicant's Electronic Signature

Please type your name for your signature. *

Date * +