Graduate Application

The first step in your on-line application is to print out your online verification form if you have not done so already. Please download and print the letter from your browser. Again, sign it and mail it in with your payment and other materials. Close the window to return.

Admission Requested for:
Status:	Full-time Part-time
Gender:	Male Female
Social Security Number: (numbers only)
Title:	Mr. Ms. Dr.
First Name
Middle Name:
Last Name:
Maiden Name:
Address:
City:
State:
Zip:
Home Phone:(numbers only)
Foreign Country (if applicable)
Personal Data
I am a legal resident of Connecticut	Yes No
Years in U.S.
Years in CT
Date of Birth: (mm/dd/yyyy)
Are any college transcripts under a name(s) other than your present name? If yes, what name(s)?:
I am a veteran.	Yes No
If yes, Date of Discharge & Number of Months in Service
Citizenship
I am a U.S. Citizen	Yes No
If no, indicate status. If Resident Alien, please mail us a copy of both the front and back sides of your Resident Alien Card	Permanent Resident Resident Alien International Student Other
Registration Number (If chosen Resident Alien)
Visa Type (If chosen Internation Student or Other)
Country of Citizenship (If chosen Internation Student or Other)
Ethnic Background: (This information is voluntary and for statistical purposes only. It has no bearing on admission to Southern.)
Education
Institutions Attended List below in chronological order (present or most recent first) all college-level institutions attended, including SOUTHERN CONNECTICUT STATE UNIVERSITY. Failure to list all such institutions may be cause for dismissal. An official transcript must be sent to the Dean of the Graduate School from each college attended.
Institution Name
Location (State)
Dates Attended (mm/yy)	to
Degree/Certif. Awarded, & Date (mm/yy)

Institution Name
Location (State)
Dates Attended (mm/yy)	to
Degree/Certif. Awarded, & Date (mm/yy)

Institution Name
Location (State)
Dates Attended (mm/yy)	to
Degree/Certif. Awarded, & Date (mm/yy)

Institution Name
Location (State)
Dates Attended (mm/yy)	to
Degree/Certif. Awarded, & Date (mm/yy)

Institution Name
Location (State)
Dates Attended (mm/yy)	to
Degree/Certif. Awarded, & Date (mm/yy)

Special Recognition: Please list any special academic recognition, honors, prizes awarded on the college level.
Have you ever applied for graduate study at Southern?	Yes No
If yes, when?
Have you ever taken graduate courses part-time at Southern?	Yes No
If yes, when?
Are any records of these courses under name(s) other than your present name?	Yes No
If yes, what name(s)?
Are other college transcripts under a name(s) other than your present name?	Yes No
If yes, what name(s)?
Applicant's Professional Experience
List most recent first
Type
Employer
Location of Firm
Dates of Employment	to

Type
Employer
Location of Firm
Dates of Employment	to

Type
Employer
Location of Firm
Dates of Employment	to
Certification Information
Do you hold Connecticut State Teacher's Certification?	Yes No
Certification Number (If chosen yes)
Program for Which You Are Applying
Program:
Certification Only (area):
Cross Endorsement Only (area):
Specialization:
Other:
Applicant's Statement
By submitting this application I declare that to the best of my knowledge and belief, the information given on this application is complete and accurate. I realize that failure to disclose fully and accurately all facts relating to this application shall be grounds for suspension or expulsion. If admitted, I pledge myself to comply, in good faith, with all the rules and regulations of the University.
Your Name:
Your Email Address: (A copy of your completed application will be sent to you.)
To help us process your application as quickly as possible, please check over the following before you submit your application. Have you... Recorded your correct Social Security Number? Printed your Verification Letter? Listed all previous colleges or universities you attended, including Southern? Notified your colleges or universities to send us your official transcripts? Entered your residency status?

Graduate Application

Personal Data

Education

Applicant's Professional Experience

Certification Information

Program for Which You Are Applying

Applicant's Statement