EMBA Admission Application
Instructions:
Complete the following application and return with a copy of your most current résumé.
You may submit your application by e-mail or by post.
By e-mail: mparis@gsu.edu
By post:
GSU Buckhead Center
Tower Place 200
3348 Peachtree Road, N.E. Suite 500
Atlanta, GA 30326
Attn: Melody Paris
All required documents do not have to be submitted at once. Only the application,
and résumé are needed to start the admission process.
Once you have submitted your application and resume, an EMBA representative will
contact you to set up a personal interview. After you have completed your personal
interview, submitted your application fee, and all of the required application documents
(including transcripts), an admissions decision will be granted. It generally takes one to
two weeks to receive the final admission decision.
Application Fee:
Please submit the $100 application fee to the above address (make checks payable to
Georgia State University). Credit cards are also accepted.
Please fill out the attached credit card authorization form (located on page 10) and fax
to: Melody Paris at (404) 413-7883. It is also acceptable to bring the filled out form
with you to your personal interview.
Questions? Call Melody Paris at 404-413-7182
1
EMBA ADMISSION APPLICATION
Personal Data
Full LEGAL
Name:
Prefix
Last/Family
First
Nickname or
name you
preferred to be
called by:
M.I.
Suffix
Maiden Name:
Home Address:
Street
City
State
Zip
COUNTY
How long have you lived in the state of Georgia?
Home Phone:
Mobile Phone:
Work Phone:
Zip code for your work location:
Preferred E-mail Address:
Gender:
Date of Birth:
Male
Female
What is your ethnicity? Please select one:
Not Hispanic or Latino
Hispanic or Latino
Race (Select all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other_______________
Note: Georgia State University is required to report data on gender and racial/ethnic groups to certain federal and state agencies, as the data
relates to civil rights compliance. The provision of this information is strictly voluntary. It is confidential and will be released only as statistical
summaries in which individuals are not identified. The information has no bearing on either admission or academic decisions but is helpful to
the University in meeting federal reporting requirements.
State of Origin (the state you were born in)
.
If you were NOT born in the U.S. please list the country you were born in:
US Citizen
Non-resident alien
Resident alien
Do you hold dual citizenship?
Yes, list ALL of the countries where you hold citizenship:
No
2
Are you in the United States on a Visa:
If yes, which type of Visa:
Employment/ Professional Experience
Total number of years of full-time (post-baccalaureate)
professional work experience:
Total number of years of managerial experience:
Please provide the following information regarding your current position only.
Employer:
Your Current Title:
Industry:
Nature/Type of Business:
Number of people under your supervision:
Time in current position:
Total current salary (including bonuses):
How much employer support do you expect?
Total tuition
Partial tuition, indicate a percentage or dollar amount
Time off
Uncertain
None
Professional References
Name:
Title:
Relationship:
Company:
Email:
Phone:
Name:
Title:
Relationship:
Company:
Email:
Phone:
Name:
Title:
Relationship:
Company:
Email:
Phone:
3
Education
List below the university from which you were awarded a baccalaureate degree:
Name of College or University
Date Attended From
City
Date Attended To
State
Country
Degree Awarded
Date Conferred
Approximate GPA
Major:
Please complete the following if you have been awarded a graduate degree:
Name of College or University
Date Attended From
City
Date Attended To
State
Degree Awarded
Country
Date Conferred
Approximate GPA
Major:
Below list the names of all other colleges/universities you have attended after high school including Georgia
State if appropriate:
Name of College or University
Date Attended From
City
Date Attended To
Name of College or University
Date Attended From
State
Degree Awarded
City
Date Attended To
Country
Date Conferred
State
Degree Awarded
Approximate GPA
Country
Date Conferred
Approximate GPA
Management Skills
What do you consider to be your field of expertise?
Accounting/ Finance
Consulting: Type
General Management
Technical/ Engineering
HR
Marketing
Other:
What sources of information or factors have led to your application to the J. Mack Robinson College of Business? (Staff,
faculty, alumni, students, internet, campus visit, information session etc.) Please be specific.
4
GMAT Exam
Have you taken the GMAT exam?
Yes If yes, what was the date?
No
If no, when do you intend to take the exam:
I plan to request a GMAT waiver
Additional Information
What other schools are you applying to (for statistical purposes only)?
How did you first hear about the Executive MBA Program at Georgia State University?
Have you heard EMBA advertisements on any of the following radio stations?
WABE (NPR):
680 The Fan:
WSB:
News Radio 106.7:
Yes
Yes
Yes
Yes
No
No
No
No
If you were referred by someone, please list their name(s) here:
5
SECURITY INFORMATION
Are you ineligible to enroll at any previously attended institution?
____ Yes ____ No
-If yes, provide relevant dates and a concise statement of the circumstances surrounding your ineligibility:
Are you currently on or have you ever been placed on academic probation, suspension, exclusion or
any other type of academic warning at any previously attended
____ Yes ____ No
institution?
-If yes, provide relevant dates and a concise statement of the surrounding circumstances:
Are you currently charged with, or have been found guilty of, any violation of academic honesty, honor
code, or conduct regulations of a previously attended institutions?
____ Yes ____No
-If yes, you must list each separate charge pending against you or with which you have been found responsible together
with the corresponding dates and a concise description of the circumstances for each:
Have you left a previous institution while there were pending charges of any violation of academic
honest, honor code, or conduct regulation?
____ Yes ____ No
-If yes, you must list each separate charge pending against you or with which you have been found responsible together
with the corresponding dates and a concise description of the circumstances for each:
6
Are you currently charged with, or have been found guilty of, any violation of a federal, state, or municipal law,
regulation or ordinance
other than minor traffic violations, including offenses for which any
____ Yes ____ No
type of first offender status have been granted?
-If yes, you must list each separate charge pending against you for which you have been convicted. Dead-docketed
charges constitute pending charges and must be disclosed. For each charge, please list the corresponding dates and
provide a concise description of the circumstances. For example, if you have been charged with D.U.I, underage
drinking, and possession, you must list all three individual charges even though they stem from the same incident:
Have you ever entered a plea of guilty, no contest, nolo contendere, or any Alford plea, or otherwise accepted
responsibility for the commission of a crime?
____ Yes
____ No
-If yes, you must list each separate charge for which you have entered such a plea or admission of responsibility,
together with the corresponding dates and a concise description of the circumstances for each:
Have you received any type of discharge from military service other than honorable discharge? ____ Yes
____ No
If yes, you must list all individual charges for which you were found responsible and a concise description of the
circumstances that prevented you from receiving an honorable discharge:
I understand that any material false statement made knowingly and willfully by me on this application, or any
documents attached hereto may, in accordance with O.C.G.A. 16-10-71, which provides that upon conviction, a
person who knowingly commits the offense of false swearing shall be punished by a fine of not more than $1,000 or
by imprisonment for not less than one nor more than five years, or both, subject me to prosecution in a court of law.
Additionally, I further understand that any such false statement may subject me to immediate dismissal from the
institution. Further, I certify that, to the best of my knowledge, the information submitted on this application is true and
complete.
Signature: ______________________________________________
Date: _______________________________
7
LAWFUL PRESENCE
The Board of Regents requires GSU to submit a copy of one of the following items listed
below. You must present an original document (one off of the list below) to the GSU
EMBA staff. The staff will make a copy to attach to your application.
Please sign this sheet and bring it with you along with one of the items listed
below to the personal interview:
• Current U.S. Passport
• Current GA Driver’s License issued by the State of Georgia after January 1, 2008
• Current GA ID Card issued by the State of Georgia after January 1, 2008
• U.S. Certificate of Naturalization
• U.S. Certificate of Citizenship
• Permanent Resident Card
I understand that any material false statement made knowingly and willfully by me on this
application, or any documents attached hereto may, in accordance with O.C.G.A. 16-10-71,
which provides that upon conviction, a person who knowingly commits the offense of false
swearing shall be punished by a fine of not more than $1,000 or by imprisonment for not less
than one nor more than five years, or both, subject me to prosecution in a court of law.
Additionally, I further understand that any such false statement may subject me to immediate
dismissal from the institution.
Further, I certify that, to the best of my knowledge, the information submitted on this
application is true and complete.
_________________________________________
______________________
Signature
Date
PLEASE SIGN THIS COPY AND BRING IT WITH YOU TO YOUR PERSONAL
INTERVIEW ALONG WITH ONE OF THE REQUIRED DOCUMENTS LISTED ABOVE.
This requirement is detailed in the following Board of Regents policies:
Policy 4.1.6 Admission of Persons Not Lawfully Present in the United States
Policy 4.3.4 Verification of Lawful Presence
8
EMBA Essay Questions
Please submit a short essay for each of the following topics. The essays should be your own
work and no more than 100 words each. You can add additional sheets if necessary.
1.) What is your long term career goal and how will an EMBA degree help you reach
that goal?
2.) Why have you chosen to apply to the Robinson Executive MBA program instead
of (or in addition to) other EMBA programs?
3.) How do you plan on leveraging your EMBA experience?
9
Credit Card Payment Authorization
Executive MBA Program
All students submitting payments by credit card must have this completed authorization form on
file before any charges can be processed.
Please fax completed form to:
GSU Buckhead Center
Attn: Melody Paris
Fax: 678-510-0976
I authorize the Office of Executive Programs (EMBA program) at Georgia State University to
process the above indicated credit card for payment in the amount of $__________________
for __________________________.
Student Name (please print) _____________________________________________________
9 digit Panther ID (to be completed by EMBA staff) ___________-____________-___________
Name on Credit Card (please print) ________________________________________________
Billing Address of Cardholder (please print) _________________________________________
____________________________________________________________________________
Cardholder’s Signature________________________________ Date____________________
* This form must be signed in order for your credit card to be processed.
______________________________________________________________________
Credit Card (check one):
___American Express#____________________________Expiration Date_________________
___MasterCard#________________________ExpirationDate___________VIN#____________
___VISA#_____________________________Expiration Date___________VIN#____________
(the VIN# is the 3-digit verification number of the back of the card in signature line)
Thank you for choosing Georgia State University.
10
Application Checklist
 Current résumé (e-mail it to Melody Paris @ mparis@gsu.edu)
 Completed essay questions.
 Application fee. Please fill out the attached credit card authorization form and bring it
with you to your personal interview. Or you may pay by check (make payable to Georgia
State University) and mail it to:
GSU Buckhead Center
Tower Place 200
3348 Peachtree Road, N.E., Suite 500
Atlanta, GA 30326
Attn: Melody Paris
 Security questions filled out and signed.
 Please bring one of the following documents to your interview:
o
o
o
o
o
o
Current U.S. Passport
Current GA Driver’s License issued by the State of Georgia after January 1, 2008
Current GA ID Card issued by the State of Georgia after January 1, 2008
U.S. Certificate of Naturalization
U.S. Certificate of Citizenship
Permanent Resident Card
 Three professional references. Contact information should include name/title,
phone, e-mail address and relationship to the person. References should be
professional – not personal/family contacts.
 Official transcripts from every college or university you have attended (even if you did not
graduate).
Send transcripts to:
GSU Buckhead Center
Tower Place 200
3348 Peachtree Road, N.E., Suite 500
Atlanta, GA 30326
Attn: Melody Paris
We will accept official transcripts electronically as long as they are sent by the
institution directly to mparis@gsu.edu.
Please note: All applications are evaluated on a case-by-case basis. Additional information will be required
to complete the process. Completion of this application does not guarantee or imply admission into Georgia
State University’s Executive MBA program.
11