Elizabeth City State University Application for Graduate Admission
Program (Check one program and/or concentration)
Master of Education in Elementary Education
Master of School Administration
Master of Science in Biology
Biotechnology
Education
Master of Science in Mathematics
Applied Mathematics
Remote Sensing
Education
Admission Term (Write the year beside the term)
Fall (August)
Spring (January)
Summer (June)
Personal Information
Full Legal Name - Last:
First:
Middle:
Maiden/Former:
Mailing Address - Street /PO Box:
County:
City:
State:
Day Phone:
Evening Phone:
Female
Citizenship (Check one):
Male
-
Military Veteran:
United States
Country:
Email:
Social Security Number (University record keeping only):
Sex:
Zip:
-
No
Resident Alien
Birth Date:
/
/
Yes
Non-resident Alien
Country of Citizenship:
If you do not have U.S. citizenship, but currently reside in the United States, what type of visa do you hold?
State of Residency* (If North Carolina resident, list County):
What month/year did residency begin?
*If applying for state residency for tuition purposes, you must complete the North Carolina Residency Form.
Ethnic Identification:
African-American/Black
American Indian or Alaskan Native
Hispanic /Latino
Native Hawaiian or other Pacific Islander
Asian
Caucasian/White
Other (Please specify):
Have you ever attended Elizabeth City State University?
No
Yes If yes, when?
Name used during previous attendance:
Have you ever been dismissed or suspended from a college or university?
Date of GRE:
Employment Status:
Company/Organization:
Title/Position:
Part-time
Yes (If yes, explain on a separate sheet)
Date of TOEFL:
Date of MAT:
Full-time
No
Unemployed
Location:
Date of IELTS:
/
Education
(List all degrees earned and the colleges/universities attended. List highest degree first.)
College/University
Degree
Major
Date Awarded
Application Certification
Your “yes” answer to one or more of the following questions will not necessarily preclude your being admitted. Your failure to be completely
truthful will be grounds to deny or withdraw your admission, or to dismiss you after enrollment. For the purpose of the following six questions,
“crime” or “criminal charge” refers to any crime other than a traffic-related misdemeanor or an infraction. Note: you must, however,
include alcohol or drug offenses, whether or not they are traffic related.
1. Have you ever been convicted of a crime?
No
Yes
2. Have you ever entered a plea of guilty, a plea of “no contest,” a plea of “nolo contendere,” or an Alford Plea,
or have you received a deferred prosecution or prayer for judgement continued, to a criminal charge?
No
Yes
3. Have you otherwise accepted responsibility for the commission of a crime?
No
Yes
4. Do you have any criminal charges pending against you?
No
Yes
5. Have you ever been dismissed, suspended, expelled, or placed on probation by any school, college, or university?
No
Yes
6. If you have ever served in the military, did you received any discharge other than honorable?
No
Yes
If you answered “yes” to any of the questions above, please explain the circumstances below on a separate sheet and submit with your application.
I certify that the information submitted above is complete and accurate to the best of my knowledge. I understand that my failure to be completely
truthful on this application will be grounds to deny or withdraw my application, or dismiss me after enrollment. The University also reserves the
right to revoke any degree or diploma that may have been awarded in reliance on information contained in the application for admission if it
subsequently transpires that this information was a fraudulent misrepresentation of fact. By signing this application, I agree to abide by the policies
and regulations of the University, and I understand this application will not be processed until I have signed on the line below. In addition, I will
promptly notify the Admissions Office of any criminal charge, or any school, college, or university disciplinary action against me that occurs
at any time after I submit this application.
Applicant’s Signature:
Date:
Thank you for completing this application.
Submit this application to: Office of Graduate Education, Elizabeth City State University,
Campus Box 943, 1704 Weeksville Road, Elizabeth City, North Carolina 27909.
Elizabeth City State Uninversity is committed to equality of educational opportunity and does not discriminate against
applicants, students, or employees based on race, color, national origin, religion, gender, age, or disability.