MASTER OF

SOCIAL WORK
PROGRAM

California University of
Pennsylvania
SUPPLEMENTAL

Application for Admission

Masters of Social Work Program, Box 90
California University of Pennsylvania
250 University Avenue
California, PA 15419-1394
724-938-4022 Phone
724-938-5977 Fax

INSTRUCTIONS TO APPLICANT: YOU MUST ANSWER ALL QUESTIONS OR INDICATE N/A (NOT APPLICABLE)

Name:______________________________________________________________________
(last)
(first)
(middle or name prior to marriage)
Present Address:____________________________________________________________
(street)
(city)
(state)
(zip code)
Phone Number: (____)________________________________________________________
Emergency
Notification:___________________________________________________________
(last)
(first)
(middle or name prior to marriage)
(street address)

(city)

(state)

(zip code)

Current Email Address________________________________________________________

NOTIFY THE SOCIAL WORK OFFICE IMMEDIATELY OF ANY CHANGE OF ADDRESS

Date of Birth:___________Birthplace:__________Citizenship:__________________
Expected Starting Date:__________ Social Security Number:____________________
Program Options: If more than one option is checked, indicate order of preference (1, 2, etc.)
_____Full-Time Regular

_____Full-Time Advanced Standing (Accredited BSW)

_____Part-Time Regular

_____Part-Time Advanced Standing (Accredited BSW)

Do you plan to file financial assistance forms? _____Yes

_____No

Have you ever served in the armed forces?

_____Yes _____No
Choose
1
If yes: _____Branch _________________Date of Discharge
Type of Discharge: _____Honorable _____General _____Less than Honorable
If other than honorable, explain and attach on a separate sheet of paper.
EDUCATION: HIGH SCHOOL, UNDERGRADUATE, PROFESSIONAL AND OTHER
TRAINING

NAME

CITY & STATE

DATES ATTENDED

STATUS (DIPLOMA ECT)

DATE RECEIVED

College Major: ___________________________

Overall GPA:______
If Social Work major, Social Work Major GPA:_____
Honors, awards:

List college, civic, community, or other activities. Circle any in which you have held an office or
served as a leader:

Professional Affiliations:

FIELD INSTRUCTION OR PRACTICUM EXPERIENCE List in chronological order (most recent

first) undergraduate and graduate field instruction experience.
POSITION

July 2013

FIELD INSTRUCTION
SETTING NAME &
ADDRESS

FROM

TO

FIELD INSTRUCTOR