Tysons Corner Campus,
8618 Westwood Center Drive Suite 100
Vienna, Virginia. 22182
Tel: (571) 633-9651
Fax: (703) 890-3372
www.uona.edu
I. PERSONAL DATA
Legal name: ______________________________________________________________________________________________________
Last Name/Family exactly as it appears on official documents)
First Name
Middle Name (complete)
Suffix, if any (i.e. Jr., etc.)
Preferred name, if not first name (choose only one): _______________________ Former last name(s), if any: ____________________
Social Security Number (if any): ________________________________________
Birth date: _________________________________________________________
Place of birth: ________________________________________________________
City/Town State/Province Country
AREA OF INTEREST
Degree Programs
Master of Business Administration (MBA)
Master of Science in Computer Science (MSCS)
Master of Science in Information Technology (MSIT)
Doctor of Business Administration (DBA)
Doctor of Information Technology (DIT)
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Resume - required by Cooperative Education Dept.
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Semester Start Date
Fall
Winter
Spring
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Certificate Programs
Certificate in Managerial Technology
Certificate in Strategic Planning
Graduate Certificate in Global Management
Adv. Graduate Certificate in Global Management
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English Language
Graduate Level Preparatory English
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Summer
ADDRESS
Permanent home address (for international applicants your home-country address)
___________________________________________________________________________________________________________
Number & Street Apartment #
___________________________________________________________________________________________________________
City/Town State/Province Country ZIP/Postal Code
Permanent home phone (_____________) ______________________ Cell phone (_____________) ________________________
Area Code
Area Code
If different from above, please give your current mailing address for all admission correspondence.
Current mailing address (from ___________ to ___________)
(mm/dd/yyyy)
(mm/dd/yyyy)
___________________________________________________________________________________________________________
Number and Street Apartment #
___________________________________________________________________________________________________________
City/Town State/Province Country ZIP/Postal Code
Phone at current mailing address (_____________) _____________________ (from ___________ to ___________)
Area Code
(mm/dd/yyyy)
(mm/dd/yyyy)
E-mail address ______________________________________________________________________________________________
List only the e-mail address that you wish to use for communication with us
If you currently attend a college or English Language Institute, include name of school here: ________________________________
Emergency Contact Information
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Name ___________________________________________________________________________________________________________
Last Name/Family exactly as it appears on official documents)
First Name
Middle Name
(complete Suffix, if any (i.e. Jr., etc.)
Address _________________________________________________________________________________________________________
Number & Street Apartment #
________________________________________________________________________________________________________________
City/Town State/Province Country ZIP/Postal Code
Telephone (______) _________________________
Alternate Telephone (______) _________________________________
If Addresses as same as above check here:
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□
Permanent mailing address
Current mailing address
Languages Spoken
First language, if other than English _________________________________________________________________________________
Primary language spoken at home, if other than English _____________________________________________________________________
II. CITIZENSHIP
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US citizen________________________________________________________________________
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Dual US citizen. List any non-US countries of citizenship ________________________________
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US permanent resident visa (Alien registration#): ______________________________________
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Other citizenship (Visa type): _______________________________________________________
How long have you been in the United States? _____________________________________________
List any non-US countries of citizenship? __________________________________________________
III. ENGLISH PROFICIENCY LEVEL
TOEFL test: Taken (date: ______________) TOEFL test score: ____________________
IELTS test: Taken (date: _______________)
IELTS test score: _____________________
IV. ACADEMIC BACKGROUND
Colleges & Universities
Are you currently enrolled in college?
Yes
No
Current or most recent college or English language institute attended ____________________________________________________
School Name______________________________________________________________________________________________________
Address __________________________________________________________________________________________________________
Number & Street
_________________________________________________________________________________________________________________
City/Town State/Province Country ZIP/Postal Code
Phone (_______) ______________________ Fax (_______) __________________________ Website: _____________________________
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Entry Date __________________ Exit Date __________________
mm/yyyy
mm/yyyy
Degree Earned ___________________________________________________________________________________________________
School Type: public
independent
2-year
4-year
List all other colleges or universities, including other programs, you have attended, beginning with your first year of college.
Secondary School, College/English
Language Institute Name
Location (City, State, Zip/Postal
Code, Country
Degree Obtained
(major)
Years attended
Language of Instruction
Please have an Official Transcript(s) sent to the Admissions Office from each institution as soon as possible.
Honors
Briefly list any academic distinctions or honors you have received in any secondary education or international equivalent (e.g. National
Merit, Cum Laude Society).
_____________________________________________________________________________________________
_____________________________________________________________________________________________
V. ACTIVITIES AND WORK EXPERIENCE
Extracurricular Activities
Please list your principal extracurricular, community, volunteer and family activities and hobbies in the order of their interest to
you. Include specific events and/or major accomplishments such as musical instrument played, varsity letters earned, etc. To allow
us to focus on the highlights of your activities, please complete this section even if you plan to attach a résumé.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Work Experience
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Please list jobs you have held (including summer employment).
Company/Organization
Name
Location
Position Title
Brief Duties
Years Employed
VI. DISCIPLINARY HISTORY
1. Have you ever been found responsible for a disciplinary violation at an educational institution you have attended, whether related
to academic misconduct or behavioral misconduct that resulted in your probation, suspension, removal, dismissal, or expulsion from
the institution?
Yes
No
If yes, explain: ______________________________________________________________________________________
2. Have you ever been convicted of a misdemeanor, felony, or other crime?
Yes
No
If yes, explain: ______________________________________________________________________________________
VII. ADDITIONAL INFORMATION
If there is any additional information you would like to provide regarding special circumstances, additional qualifications,
professional certifications, achievements, etc., please do so in the space below or on an attached sheet.
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
VIII. REFERRAL
Who referred you to UNA or how did you otherwise learn of the university? _________________________________________________
IX. SIGNATURE AND PAYMENT
Application Fee Payment
Check the appropriate box:
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Credit Card (complete credit card authorization form)
Personal Check (made payable to the University of North America)
Money Order (made payable to the University of North America)
Required Signature
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I certify that all information submitted in the admission process; including the application, the personal essay, any supplements,
and any other supporting materials is my own work and accurate to the best of my knowledge. I understand that I may be subjected
to a range of possible disciplinary actions, including admission declination or expulsion, should the information I have certified be
false. In addition, I authorize the release of my admission decision to my current institution.
Signature ________________________________________________________________________________ Date ___________________
mm/dd/yyyy
X. OPTIONAL
Responses to the following questions are used for reporting purposes only and will not be used to grant or deny a student’s admission
to Brydon English Language Institute. Brydon English Language Institute is committed to fulfilling its mission without discrimination
on the basis of race, color, national origin, religion, age, sex, gender, sexual orientation, disability, or veteran status.
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Female
□
Male
US Armed Services Veteran?
Yes
No
Marital status:
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Never married
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Married
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Widowed
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Separated
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Divorced
If you wish to be identified with a particular ethnic group, please check all that apply:
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African American, African, Black
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Native American, Alaska Native (Tribal affiliation ____________________)
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Asian American (country _________________________________________)
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Asian, incl. Indian Subcontinent (country ___________________________)
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Hispanic, Latino (country _________________________________________)
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Mexican American, Chicano
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Puerto Rican
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Native Hawaiian, Pacific Islander
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White or Caucasian
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Other (specify ________________________________________
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ADMISSION REQUIREMENTS
PROGRAM APPLICATION REQUIREMENTS
Students who want to apply for admission to the University of North America must submit the following documents to the Office of Admissions:
1.
2.
3.
An official application for admission.
A non-refundable application fee of $100.00 (check or money order payable to the “University of North America” in U.S. currency)
Copy of identification (i.e. driver’s license, ID card) and, for Permanent Residents, a copy of a Green Card.
The University of North America (UNA) is a multicultural, multi-program institute that places a strong emphasis on customer service for its students.
Admission policy to UNA is based on equal opportunity and open access to all interested candidates of a diverse background that are interested in
furthering, improving and/or changing their education and professional career.
UNA is committed to fulfilling its mission without discrimination on the basis of race, color, national origin, religion, age, sex, gender, sexual
orientation, disability, or veteran status. UNA is guided by the Family Educational Rights and Privacy Act of 1974 (FERPA).
This section for Staff Use Only:
Student’s Official Transcript Received
Non-refundable Application Fee Received
Copy of Identification Received
Form of Identification _____________________________________________________________________
Identification Number _____________________________________________________________________
Expiration of Identification _________________________________________________________________
Student is eligible for CPT
Student is not eligible for CPT
(Please attached copy of identification to completed application)
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