Graduate Application - Clinical Counseling

If there are any questions, please contact CMU Park Hills at 573-518-2301 or email Teresa Keown, Director, MSCC.
All fields marked with * are required.
   
Today's Date:  
Anticipated First Semester & Year  Enrollment: Full-Time  Part-Time
Applying as: Graduate Degree Program Applicant  Nondegree/Special Student
Are you currently enrolled at or have you previously attended or applied to attend Central Methodist University?
Yes  No
If yes, as Undergraduate  Graduate  Nondegree/Special Student                                  
Attendance Dates:              
 
Personal Information:
Legal Last Name:*  
First Name:*  
Middle Initial:
Maiden Name:
Spouse's Name
Spouse's Work Phone:
Address: *
City:*
State:* 
ZIP:*
County: (if in Missouri)  
Country: (if not U.S.)
Home Phone:*
Cell Phone:
Email Address:*
     
Gender: Male  Female
Birthday:*  
Social Security Number:*  
Racial/Ethnic Heritage (check one box)
  African American  American Indian or Alaska Native  Southeast Asian  Other Asian/Pacific Islander
  Hispanic/Latino    Caucasian/White
Have you served on active duty in the U.S. Armed Forces?  Yes  No
English Language Proficiency tests you have taken or plan to take:  
TOEFL: Yes  No                 Date Taken/Scheduled:       Score:  
Other     Yes  No                 Date Taken/Scheduled:       Score:  
     
     
Are you a U.S. Citizen? Yes  No  
If no, indicate country of Citizenship:  
Native Language:  
     
Have you ever been convicted of a felony in this state or any other state?  Yes  No  
If Yes, please explain: Year of Conviction:  
 
     
Are you a legal Missouri resident and/or do you claim legal Missouri residence for tuition purpose?  
Yes  No  
Do you hold a valid Missouri Drivers License?  
Yes  No    
     
Contact in Emergency::  
Name:  
Relation:  
Phone:  
Alternate Phone:  
     
High School of Graduation:  
Name:   City:   State:    
     
Graduation Date: Check if you were home schooled  
   
Undergraduate and Graduate Institutions Attended:  
Name: Dates Attended:
Degree: Semester Hours:
       
Name: Dates Attended:
Degree: Semester Hours:
       
Name: Dates Attended:
Degree: Semester Hours:
       
Name: Dates Attended:
Degree: Semester Hours:
Undergraduate GPA: Graduate GPA: No. of Graduate Hours Earned:
Graduate Record Exam (GRE) scores if available:  
Verbal:    Quantitative:    Analytical:    
Miller Analogy Test:
Date Taken:
     
Licensure: Teaching, Nursing Counseling, Etc....    
Do you currently hold a license Yes   No If Yes, State:  
Certification Type: Expiration Date:
Do you seek further licensure Yes   No    
If yes, specify type:    
       
How were you introduced to the Graduate programs at Central Methodist University? (check all that apply)  
Internet  Alumnus  Faculty  Educational Agency  Advertisement  Co-Worker  Printed Materials
Friend   Educational Fair           Undergraduate at CMU         Other:
   
Additional Information:    
 
     
Note of Non-Discriminatory Policy: Central Methodist University admits students of either sex, any race national or ethnic origin to all rights, privileges, programs, and activities generally accorded or made available to students at the school.  It does not discriminate on the basis of race, gender, disability, or national and ethnic origin in administration of its educational policies, scholarships, loan programs, athletic, and other school administered programs.

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