SSU Extended Education: Graduate Application Form

FOR OFFICE USE ONLY:

Accom. Status	Enroll Status	Res. Status	Citizenship
Perm. Res.	CC trans.	Degree Held	Inst. of Origin
Trans. units in progress	Miscellaneous

BEGIN APPLICATION HERE:

We encourage you to attend one of our Information Meetings to learn more about these programs. Check the Information Meetings web site for current dates for graduate programs.

This form is ONLY for mail or fax. Fill in, print, then mail or fax to: SSU Extended Education, 1801 E. Cotati Ave., Rohnert Park, CA. 94928

Attach $55 (U.S.) application fee payable to SSU. The fee is nonrefundable and may not be tranferred to another term. Response to each item is mandatory unless otherwise indicated.

IMPORTANT NOTE:

In addition to this form, individual graduate programs may require supplemental application materials. (See item 14a.)

1. Legal Name (last/first/middle)

2. Other name(s) that may appear on your academic records:

3. Please check the program to which you are applying:

MA Spanish
MA Organization Development
MA Psychology, Depth Psychology
MS Computer and Engineering Science

3a. Term and year for which you are applying:

Fall
Spring
Summer
Intersession
Year

Use of Social Security Number:
SSU uses the social security number as the identifier for student records maintained in your association with the campus and, if needed, to help collect debts owed the university. Applicants are required to include their social security number in designated places on applications for admission pursuant to authority contained in Title 5, California Code of Regulations, Section 41201.

If you do not have a social security number at the time you file the application, leave the item blank; the campus will assign a substitute number.

4. Social Security Number:

If you have previously applied to or attended this campus, please list:

5a. Date of Previous Application:

Last term and year attended:

5b. Previous student file number (if different from SSN):

6a. Current Mailing Address

6b. Permanent Address (if different from current address:

7. Contact Information

7a. Phones		Check preferred number
Home Phone
Daytime Phone
Cell Phone

7b. Email

8. Birth Date

9. Sex

10. Name of intended degree

MA Spanish
MA Organization Development
MA Psychology, Depth Psychology
MS Computer and Engineering Science

11. Degree Objective

Master's

12. What was your baccalaureate major/minor?

Major Minor

13. Are you eligible to reenroll at all institutions previously attended?

yes
no

If no, please explain:

14. Print the names and locations of all colleges and universities attended, even if no coursework was completed. Begin with the last institution attended. Attach a separate sheet if you need more space. For units in progress and planned, see the next list below.

Institution	Location	From (mm/yy)	To (mm/yy)	Transferable units completed	Degree received	Date to be received	Office Use Only

14a. Please send two official, sealed transcripts showing the most recent 60 semester units you have attempted (even if unrelated to your major), as well as award of the bachelor's degree (include Summer and Extension transcripts) to SSU Extended Education, 1801 E. Cotati Ave., Rohnert Park, CA 94928-3609. Add "attention to" on the envelope and use the appropriate name from the list below:

Program to which you are applying:	Contact email:
MA Spanish	Karen Fischer
MA Organization Development NOTE: The MA Organization Development program has a Departmental Application to OD Program [pdf format]. Please complete both this application and the additional form if you are an applicant to that program. Please include them together in one envelope for mailing to the above address.	Karen Fischer
MA Psychology, Depth Psychology NOTE: The MA Psychology, Depth Psychology program has a Program Application [pdf format]. Please complete both this application and the additional form if you are an applicant to that program. Please include them together in one envelope for mailing to the above address.	Karen Fischer
MS Computer and Engineering Science	Farid Farahmand

15. List below college courses in which your are currently enrolled and additional courses you plan to complete (including summer school) before entering the program. Attach a separate sheet if more space is needed.

Courses in Progress:
Institution	Term/Year	Dept. Course No. and Title	Unit Value

Courses Planned:
Institution	Term/Year	Dept. Course No. and Title	Unit Value

16. I have taken the Written English Proficiency Test or equivalent junior-level writing exam.

yes
no

17. Employment History: You may omit employment not relevant to your professional academic goal. Include naure of work and dates.

If you wish to apply for financial assistance, contact the Financial Aid Office at (707) 664-2389 for an application form or check the Financial Aid website: www.sonoma.edu/finaid/

18. Permanent residence (county). If you live in California, list county of residence.

19. Country of Citizenship *

19a. Enter your citizenship code:

If Immigrant (I-551) or Other Visa, date issued: (You must be prepared to submit verification.)

If Other Visa, specify what type:

19b. If you were born outside the U.S., what year did you or will you move to the U.S.?

20. Enter your ethnic/racial identity. To conform with the new guidelines of the Federal Office of Management and Budget, the CSU must collect from applicants detailed information about their ethnic and racial backgrounds.

If you select "yes" in Question 20a, a response to Question 20b is required. Please do not select more than one response in Question 20b as only ONE response is allowed. After completing Question 20b, please answer Questions 20c and 20d. If you have selected "no" or "decline to state", do not answer Question 20b.)

20a. In regard to your ethnicity, do you consider yourself Hispanic or Latino? If "no" or "decline to state" please go to Question 20c.

yes
no
decline to state

20b. If you indicated (above that you consider yourself Hispanic or Latino, please select the ONE category below that best describes your background:

Argentinean
Bolivian
Chilean
Colombian
Costa Rican
Cuban

Dominican (Republic)
Ecuadorian
Guatemalan
Honduran
Mexican
Nicaraguan

Panamanian
Paraguayan
Peruvian
Puerto Rican
Salvadorian
Spaniard

Uruguayan
Venezuelan
Other Central American
Other South American
Other Hispanic or Latino
If Other, specify:

20c. What is your race? (Mark one or as many races below as appropriate for you.) All graduate applicants must respond to Question20c. If you select "decline to state", then you cannot choose any other boxes. The U.S. Census identifies the followin races: White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or Pacific Islander. These racial categories, as well as many sub-categories, are listed below. You may mark as many races as are appropriate to you. Please mark only one sub-category for each race that you select.

White

Black/African American

American Indian or Alaska Native

Asian

Pacific Islander

European
Middle Eastern
North Africa
Other White
Specify:

African American
Black
Haitian
Other African/Black
Specify:

Achomawi/Achumawi
Cahto
Cahuila
Chemehuevi
Chumash
Costanoan/Ohlone
Cupeno
Gabrielino/Tongva
Hupa/Hoopa
Kanuk
Kumeyaay
Luiseno
Maidu
Miwok
Mojave
Ohlone
Paiute
Pomo
Quechan
Serrano
Shoshone
Tolwa
Wappo
Washoe
Western Mono
Wintun
Wiyot
Yokuts
Yuki
Yurok
Latin American Indian
Other American In. Tribe
Specify:

Other Alaska Native Tribe
Specify:

Asian Indian
Bangladeshi
Bhutanese
Burmese
Cambodian
Chinese
(except Taiwanese)
Filipino
Hmong
Indo Chinese
Indonesian
Iwo Jiman
Japanese
Korean
Laotian
Malaysian
Maldivian
Nepalese
Okinawan
Paskistani
Singaporean
Sri Lankan
Taiwanese
Thai
Vietnamese
Other Asian

Specify:

Carolinian
Chuukese
Fijian
Guamanian or Chomorro
I-Kiribati
Kosraean
SaipaneseMariana Islander
Marshallese
Natie Hawaiian
Ni Vanatu
Palauan
Papua New Guinean
Pohnpeian
Saipanese
Samoan
Solomon Islander
Tahitian
Tokelauan
Tongan
Yapese
Other Melanesian
Other Micronesian
Other Polynesian
Other Pacific Islander

Specify:

Opt Out:

Decline to State

21. If the CSU is asked to report only ONE summary race/ethnicity description for you please choose the ONE category that you want us to report.

22. Have you ever been on active duty in the U.S. military services? If yes, attach or send a copy of DD214 or DD295 for evaluation of academic credit to the admission office of each campus to which you apply.

Yes, I have been on active duty
Yes, I am a dependent of an active duty serviceman

23. Do you have an RN (Registered Nurse) license?

yes
no

24. OPTIONAL: If you have a physical, perceptual, pschological or learning disability, check this box. Special services may be available to accommodate your disability.

25. Certification to be read ad signed by all applicants to certify the accuracy of the information provided.

I certify under penalty of perjury that I have provided complete and accurate responses to the items on this application. I further certify all official documents submitted in support of this application are authenticand unaltered records that pertain to me. I authorize release of any information submitted by me in connection with my application to anperson, firm, corporation, association or government agency, but only to verify or explain the information, obtain pertinent records, or in connection with perjury proceedings. My signature certifies the accuracy and compleeteness of the information provided. I understand that any misrepresentation may be cause for denial or cancellation of admission or enrollment.

Applicant's Signature

Printed Name

Signature

Date

Please tell us, in brief, about your interests and goals, academic and otherwise:

Sonoma State University School of Extended Education

SSU Extended Education: Graduate Application Form

Program to which you are applying:

Contact email: