There is a $50 application fee if you have not been enrolled as a graduate student at IUPUI in the School of Education before.  Make your check payable to IUPUI and mail with application to address at bottom of this page.    Once registered, Graduate Course Fees will be billed ($304.03 per credit hour / Fall08).

I am taking courses for License Renewal _____Yes
I am taking courses for a Certification/Master’s Program _____Yes

 

NAME: First _______________________ M.I. ______ Last _______________________

Maiden and/or Previous Last Name(s) ______________,_______­­­­­_________,______________­­­

SSN # last 4 digits______ Gender: M__ F __    DOB ____ / ____ / ____
Ethnic Group (opt) ____

University ID# ________________ Phone: (        ) ______ - _______
E-mail: _________________

Residence Information: Incomplete information will result in a preliminary determination of non–resident and higher fees.

Legal State of Residence ______
Have you lived in Indiana for the past 12 consecutive months? Yes ___ No ___

Current address        Dates (Month/Year) from __________________to ___________________          

Previous addresses up to 5 years (complete - if at current address less than one year)

Citizenship:        
USA-Citizen    Permanent Resident #_____________     Visa (F-1, J1, J2, other ______) 
    
If not a USA-citizen, country of citizenship _______________________________________

Have you previously attended any Indiana University?

Yes____ No____ Year _____ Campus_______

Educational History

I understand that withholding pertinent information requested on this application or giving false information on this application will make me ineligible for admission, or will make me subject to cancellation of admission if admission has already been granted, or dismissal if already enrolled. I certify that all statements on this application are correct and complete. I give my permission to officials at all institutions I have attended to release information needed by the University to substantiate statements I have made on this application.

Signature: _______________________________________ Date: ___________________

Return form (and payment if applicable) to:   Graduate Admissions Coordinator, IUPUI School of Education – ES 3131, 902 W. New York St., Indianapolis, IN 46202

  School of Education Use Only - submit to Graduate Office

Academic Program: EDUC 9 _____  Academic Plan: License Renewal _____    Other ______

Semester:    _________ Summer 2009            Term  Code: ____________

Special Handling __________________ Approved by ___________Date ___________