Departmental Application for Admission To
College Student Affairs

Please complete application and then Print

 


Date of Application:
Name (last, first, m.i.):
Current Address:
City: State:  Zip:
Home Telephone     Work Telephone
Fax Number      
E-mail Address
Social Security Number:      
Date Baccalaureate Degree Received:  
Major:
Institution:
Apply to begin (check one): Fall       Spring     Summer     Year
  

Work Experience: List your work experience chronologically, beginning with the most recent. They may include family child-care experiences and volunteer work. For each, indicate whether the experience was full-time or part-time.

 From              To
Mo./Yr.         Mo./Yr.
Role or Title

Location

Full/Part-time
(hrs. per week)

 

References: List two persons who will be completing the Admissions Recommendation Form:

Name

Title

Address

Phone

This application must be signed and dated:


Signature_________________________     Date______/______/_____                                                   

RETURN TO:   Department of Counseling & Student Development
                            Eastern Illinois University, 600 Lincoln Avenue, Charleston, IL 61920-3099