Part A: Student Information

Social Security Number:  

Full Name (Last, First Middle): 

Maiden Name: 

Street Address : 

City, State Zip:

Email Address: 

Telephone Number (Home):      Telephone Number (Work):

Fax Number:

Date of Birth (MM/DD/YYYY):

List the cities and states where you have lived during the past 12 months (give dates):

Are you a United States citizen? Yes  No   

If no, indicate country:

Have you obtained a visa? Yes  No  

Type of Visa:    Date of initial entry into the US: 

Have you ever been charged with a crime, which would prevent your licensure or certification as an educator, administrator or counselor?  Yes  No

Part B:  Educational Background

Name of High School: Graduation Date:

Street Address and State of High School: 

University Granting Bachelor's Degree:   Graduation Date:

Degree:   Major:   GPA:

University Granting Master's Degree:   Graduation Date:

Degree:   Major:   GPA:

List all colleges/universities attended (where you enrolled for graduate courses) since receiving your bachelor's degree.  (Failure to do so may result in dismissal):

School Name                City/State                   Term/Years Attended               Degree Received 

Have you ever been dismissed from any college? Yes No

If yes, please explain when you were dismissed and why: 

Have you previously taken Northern's correspondence, extension or workshop courses? Yes No 

If so, when? 

Have you ever applied for admission to another graduate school? Yes No 

If yes, what college?   When:

Were you admitted?  Yes No

If you began a degree program and discontinued graduate study, state reasons for discontinuing:

Part C:  Occupational Data

Have you gained certification by completing a teacher education program? Yes No 

Do you have a valid certificate? Yes No    If yes, specify state

Beginning with latest date, list experience for the past five years:

Title of Position            Date              Place

Part D:  Professional Objective

Are you planning on working on a master's degree at Northern? Yes No

What program do you plan to follow?

• Master of Science in Education 

Elementary School Administration 

Secondary School Administration 

Guidance and Counseling (Agency)

Guidance and Counseling (School)

• E-learning

Master of Science in Education in E-learning Design and Instruction

Master of Science in E-learning Technology & Administration 

• Master of Science in Education, Teaching & Learning with Emphasis in...

Elementary Classroom Teaching 

Language & Literacy 

Secondary Classroom Teaching 

Special Education 

Health, Physical Ed & Coaching 

Educational Studies 

• Non-Degree

Certification 

Transfer to another college 

Other

What year do you plan to begin Graduate Study?   

What semester do you plan to begin?  Fall Spring 1st Summer Session 2nd Summer Session   

Application Agreement: I hereby certify that the information on this application is accurate in every respect, and I understand that any intentional misrepresentation may be cause for revocation of admission. I also certify that I will inform the Office of Graduate Studies of any change in the above record which occurs between now and the opening date of the term for which I am applying. I agree to comply with the regulations and requirements of Northern State University and to cooperate with the authorities and any fellow students to maintain high standards of conduct and scholarship. It is understood that I accept registration as a student at Northern State University subject to the above provisions. Enrollment in classes offered through extension is open to all qualified students without official admission to the university or a college program, but enrollment by this method does not constitute admission.

Check this box to agree to the Application Agreement in the prior paragraph: 

Reminder:  PROVIDE TWO LETTERS OF RECOMMENDATION (THREE IF APPLYING FOR A GRADUATE ASSISTANTSHIP). REQUEST ONE OFFICIAL COPY OF YOUR TRANSCRIPT TO BE SENT TO THE OFFICE OF GRADUATE STUDIES. A $35.00 NON-REFUNDABLE MATRICULATION FEE MUST BE PAID BEFORE ADMISSION CAN BE CONSIDERED. Please return to the Office of Graduate Studies. Northern State University is an equal opportunity institution. The policy of Northern State University is to provide equal opportunities for employment, admissions and services to all individuals. Contact the affirmative action office on campus in the Administration Building, Room 213. Phone 1-800-678-5330.
 

(Counseling students are required to take for acceptance the Graduate Record Exam (GRE) and score at least an 800 on the verbal and quantitative sections combined, and at least a 2.5 on the analytical writing section.  Counseling students are also required to go through an interview process with graduate faculty from the Counseling Department for acceptance).

Marital Status:  Married Unmarried Choose Status        Gender: Male Female Choose Gender        Race:  Black/Non-Hispanic Asian/Pacific Islander White Caucasian Spanish Surname American Indian Do not wish to respond Choose Race