GIS Program Application For Admission
Page 1
GIS CERTIFICATE PROGRAM
1. PERSONAL INFORMATION
Student Last Name/First Name/Middle Initial:
Current Address/Apt #:
City/State/Zip:
Social Security Number:
Date of Birth:
Home Phone:
Home E-mail:
Work Phone:
Work E-mail:
Date of High School Graduation/GED:
School Attended:
I am applying for admission to the
*
Fall
Spring
Year
Please indicate your ethnicity/race (OPTIONAL):
Are you Hispanic or Latino?
Yes
No
Please indicate one or more:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
2. Previous Colleges/Universities Attended
Name/Location:
Degrees/Credits Earned:
Dates Attended:
3. Previous Colleges/Universities Attended
Name/Location:
Degrees/Credits Earned:
Dates Attended:
4. Please list/describe course work completed in geography, information technology, computing, programming, and geographic information systems (GIS). This information will be taken into consideration when determining whether
GIS 100 Fundamentals of GIS
will be required as a prerequisite. If appropriate coursework is not listed, students will be required to take GIS 100.
*
5. Have you ever taken an online course?
Yes
No
6. Employment Information
Current Employer:
Address:
City/State/Zip:
Phone #:
Position/Title:
7. Will your employer provide tuition assistance for the GIS Certificate Program?
Yes
No
8. I understand that this is a non-degree program but that I will earn undergraduate college credit upon successful completion of each course and a Certificate in GIS upon completing all required course work. The information I have provided on this application is honestly presented.
Name:
Date:
