Application for Admission Endorsement Programs
Application for Admission Endorsement Programs FAX TO: UTAH VALLEY UNIVERSITY Admissions Office 801-863-8913 For more information, please call Utah Valley University School of Education, Graduate Studies 801-863-6723 Application Date _________________ Admission application for ___ Fall ___ Spring ___ Summer Year_________ APPLICATION FOR ENDORSEMENT PROGRAM (Please enter information in fields) ___ New student to UVU, $35 ___ Readmission to UVU UVU ID (if known) ___________ Social Security Number _________________________ Name _____________________ Program: END _______________________ ___________ Last First Address ____________________ Attended under what last name? _______________ _______________________ ___________ Street _______________ Middle City Maiden _______________ State Telephone __________________ Email address __________________ Birthdate ___________________ Birthplace _________________ Zip Code _____________ City _______________ State Country ___ Male ___Female Are you a US citizen? ___Yes ___No (Submit proof of citizen ship if born outside the United States.) If no, are you a resident alien? ___Yes___No (If yes, submit a copy of your Resident Alien Card, front and back, with this application.) Is English your native language? ___Yes ___No If not English, what is your native language? ____________ Predominant Ethnic Background (check one- requested for federal reporting) ___White ___Hispanic/Latino ___Pacific Islander ___Asian ___Black/African American ___American Indian/Alaskan Native - Please list tribe ____________ I claim legal residence in ______________________ If not Utah, how long have you continuously resided here? ____ _____ State Years Emergency Contact Name___________________________________ Emergency Contact Address ____________________ Months Relationship _________________ ___________________ ____________ _______________ Street City State Zip Code Emergency Telephone ____________________________________ Please list the school and district in which you are employed. School District Name of charter/private school City ________________ ______________ Are you teaching in a charter/private school? __________________ ______________ Which endorsement are you pursuing? ___ Dual Language Immersion ___ Gifted and Talented ___ Educational Technology ___ Elementary Mathematics ___ English as a Second Language ___Reading I Statement: I understand and agree with the terms of application to an endorsement program at UVU. I certify that all information provided on the following pages is accurate and correct. I understand that if information is not accurate or correct, I will be dismissed from the program. Signature _________________________________ Date __________________________ This page is used for administrative purposes only. Acceptance into a graduate program is determined by the information submitted on the additional documentation provided. Utah Valley University is an equal opportunity institution and does not base acceptance on age, race, gender, marital status or nationality, the collected data is only used for federal and state reporting purposes. All application materials become property of UVU and will not be returned. OFFICE USE ONLY RES _______ ADMISSIONS _______ PROCESSED ON _______
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