Virginia Union University
Department of Social Work
For Department Use Only
Date application received: _______
Date essay received: ___________
Date of interview: _____________
Disposition: __________________
APPLICATION FOR ADMISSION TO THE
SOCIAL WORK PROGRAM
Please print this application and then sign it.
Part I.
Identifying Information
Name:
ID#
Last
First
MI
Date of Birth:
Local Address:
City
Local Telephone Number: (
State
Zip Code
State
Zip Code
)
Permanent Address (If different from above):
City
Home Telephone Number: (
)
Father’s Name:
Occupation:
Mother’s Name:
Occupation:
Guardian’s Name:
Occupation:
(If other than parent)
In Case of Emergency Contact:
Name:
Address:
City
Telephone Number: (
State
Zip Code
)
Relationship of this person to you:
Part II .
Academic Information
Present or Intended Major:
Minor:
Name of Advisor:
Current GPA:
Expected Date of Graduation:
List courses, if any, that you have failed (D or F) since entering Virginia Union University.
Course
Semester
Grade
1.
2.
3.
4.
Part III.
Employment/ Volunteer Activities
List all previous employment. (High School and College)
Employer
Position
City, State
Dates
List all volunteer activities (High School and College)
If presently employed please provide the following information:
Name of Employer:
Your Position:
Work Schedule:
Part IV.
References
Please provide us with contact information for the two references that you have provided.
Name
Address
Telephone Number
1.
2.
Part V.
Other Information
The following questions are required of all applicants. Omission of any information may result in our
inability to process your application. This information will not affect your admission to the social work
program, but it may limit the type of placement setting to which you will be assigned in the future.
False statements on this form would be evidence of unethical behavior and consequently grounds
for termination from your field placement and/ or the Department of Social Work & Sociology.
You may attach additional pages, if needed, to answer these questions.
1. Have you ever used another name under which records may be filed concerning your
application, or your education, training, or experience leading to your application (such as a
maiden name, or your name prior to adoption)?
Yes __
No __
If YES, please explain.
2. Have you ever been convicted of a felony?
Yes __
No __
If YES, please attach a complete and comprehensive explanation to this document.
3. Have you ever been charged with and found responsible for any type of abuse of a child, an
elder or any other vulnerable person (such as someone with physical, cognitive or mental
disabilities)?
Yes __
No __
If YES, please attach a complete and comprehensive explanation to this
document.
4.
Are you a citizen of the United States of America, or a legal immigrant?
Yes __ No ___
If NO, do you have a VISA that allows you to be here legally (such as a
student VISA or work VISA?)
Yes ___
No ___
If YES, please attach a copy of the VISA to this document.
If NO, please attach a complete and comprehensive explanation to this
document.
By signing this application, I hereby give permission to members of the Social Work faculty to contact the
references listed in Part IV.
Signature:
Date:
Signature of Department Chair: __________________________________ Date: __________________
VUU/SWK Program
Revised January 2016
For Department Use Only
Department and Board Members present
at interview: