Admission Application
Master of Social Work Program
Date: _____________________________
Panther ID: ____________________________
First Name: ____________________________
M.I.: ___
Last Name: ____________________________
Address: ________________________________________________________________________________________
City: ____________________________
State: ___
Zip Code: _________
Gender: _________
Phone Number: (Home) _____________________ (Work) _____________________ (Cellular) ____________________
Please check on of the following: State Residency in ☐ Florida ☐ Other (State/Country): ______________________
☐ I am a citizen/national of the United States
☐ I am a lawful permanent resident
☐ I am an alien authorized to work
☐ I am an international student (I-20) authorized to work
Email: _____________________________
Date of Birth: ______________
For which program are you applying?
Choose an item.
For which semester and year are you applying?
Are you employed by the State of Florida? ☐ No
Place of Birth: _______________
Semester: ____________________
Year: _________
☐ Yes, specify agency: ___________________________________
Please provide the following information about your undergraduate degree:
Undergraduate University/College: __________________________________________________________________
Undergraduate Degree and Major _____________________________ Graduation Year: ____________________
*Liberal Arts Background: List one course taken in each of the following areas. If you are missing any prerequisites,
note your plan to complete them prior to beginning our program, or within the first semester of admission
Human Biology
Course
Number
__________
Statistics
__________
________________________
_____
________________________
Social Science*
__________
________________________
_____
________________________
Social Science*
__________
________________________
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Social Science*
__________
________________________
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Social Science*
__________
________________________
_____
________________________
Course Title
Grade
Institution Course was taken
________________________
_____
________________________
*12 semester hours in any of the social and behavioral sciences is required (psychology, sociology, economics, and/or
political science).
Employment History
Please list all paid work (full and part-time) for at least the last five (5) years, including part-time work as a student,
beginning with your most recent employment.
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Social Work and/or Human Services Related Employment
Organization
Dates
From/To
__________
Hours Per
Week
__________
Position Held
Job Duties
__________
Location
City/State/County
__________
__________
________________________
__________
__________
__________
__________
__________
________________________
__________
__________
__________
__________
__________
________________________
__________
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________________________
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________________________
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__________
__________
__________
________________________
Dates
From/To
__________
Hours Per
Week
__________
Position Held
Job Duties
__________
________________________
Non-Social Work Employment
Organization Location
City/State/County
__________ __________
__________
__________
__________
__________
__________
________________________
__________
__________
__________
__________
__________
________________________
Ethnicity:
___________________________________________________________________________________
(Optional: We use this for reporting purposes. Your response will not affect your admission.)
Through what sources of information (alumni, faculty, co-workers, etc.) did you become interested in the Florida
International University M.S.W. program?
_________________________________________________________________________________________________
Are there any physical or emotional factors that should be considered in planning your program?
If so, please describe:
_________________________________________________________________________________________________
Please indicate any languages, other than English, which you speak, read, or write fluently:
_________________________________________________________________________________________________
Criminal History Notice:
Applicants are advised that Florida and most other states may restrict or deny social work licensure for persons with a
felony conviction. For more information, applicants are advised to review Chapter 456.013 (3) of the Florida Statutes at:
http://www.doh.state.fl.us/mga/491/soc_home.html
Additionally, many agencies require a criminal background check prior to approval for field placement. Students with
felony and/or certain misdemeanor convictions may be ineligible for some field placements due to agency restrictions. If
you have a criminal history, please be aware that this may affect your ability to complete some field placements or obtain
a license. Such applications, therefore, are urged to consult with faculty at the School of Social Work prior to embarking
on their social work education.
☐ I accept the above terms and conditions ☐ I do not accept the above terms and conditions
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