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

	Year*
	2012 2013

	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 used ESRI's Arc GIS Desktop software?
	Yes No Skip Question 6 and 7 If yes, please specify

	6. How long?

	7. What version(s)?

	8. Have you ever taken an online course?
	Yes No

9. Employment Information

Current Employer:
Address:
City/State/Zip:
Phone #:
Position/Title:

	10. Will your employer provide tuition assistance for the GIS Certificate Program?
	Yes No

	11. How did you hear about the GIS Certificate Program offered by Elmhurst College?

12. 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: