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
_______