FORM 2
INFORMATION SHEET
Important – Please complete this form and return it with your statement of reasons to:
Western Illinois University
Department of Educational and Interdisciplinary Studies – Horrabin Hall 115
1 University Circle
Macomb, IL 61455
THIS IS AN INFORMATION SHEET ONLY. COMPLETION OF THIS SHEET WILL NOT GAIN YOU
ADMITTANCE INTO THE DEPARTMENT OR THE GRADUATE SCHOOL, BUT THIS FORM MUST BE
COMPLETED AND SENT TO THE EIS DEPARTMENT. ALL APPLICATIONS MUST BE SUBMITTED
TO THE GRADUATE SCHOOL.
PLEASE TYPE OR PRINT
DATE _______________________________________
NAME ______________________________________________________________________________
ADDRESS __________________________________________________________________________
HOME TELEPHONE _____________________ WORK TELEPHONE ______________________
E-MAIL _____________________________________________________________________________
EDUCATION: List the names of all of the colleges and universities you have attended.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Undergraduate Major(s) ___________________ Undergraduate Minor(s) ___________________
Do you hold a valid teaching certificate? YES _____ NO _____
____________________________________________________________________________________
Do you intend to enroll:
Will you enroll at:
Full-time (9 or more credit hours) ____
Quad Cities Campus ____
Part-time ____
Macomb Campus ____
Special Comments or Requests: