Graduate Certificate Application

NAME

First Name

Preferred First Name

Middle Name

Last Name

Previous Name/Maiden Name

DEMOGRAPHICS

Citizenship Type:

Country of Citizenship

Social Security Number (no dashes)

Birthdate

Are you Hispanic or Latino?

Yes

Select one or more of the following races:

Sex

Gender

Other

CONTACT

Cell/Primary Phone Number

Home Phone Number

Email Address

Current Mailing Address

Country

Street

City

Region

Postal Code

Is your permanent address different than your current mailing address?

Permanent Address

Country

Street

City

Region

Postal Code

ENROLLMENT INFORMATION

Which certificate do you wish to enroll?

When do you wish to enroll?

Have you previously been admitted or enrolled at Millsaps College?

Yes

Millsaps ID number

EDUCATIONAL HISTORY

Please list the institutions that you have attended beginning with the institution from which you received your undergraduate degree, followed by institutions from which you have earned any additional undergraduate credits, even if a degree was not earned.

Search for your school

CEEB Code

Major

Degree Type

GPA (Round to the nearest tenth)

Unofficial Transcript(s)

Please upload your unofficial transcript of your baccalaureate degree. If you took a statistics course and it is not included with a grade on this transcript, please email it to mbamacc@millsaps.edu.

Note these transcripts will be used for admissions review only. If you choose to enroll, official transcripts will be required PRIOR to the start of the enrollment term.

Have you completed a statistics course?

ADD ANOTHER College/University

Yes

Search for your school

CEEB Code

ADD A 3RD College/University

Yes

Search for your school

CEEB Code

EMPLOYMENT INFORMATION

Are you currently employed?

Employer Name

What is the classification of your current employment?

What is the industry classification of your current employer?

FINAL STEPS

How did you hear about the certificate? (Select all that apply using the ctrl or shift keys)

Referral Name

What prompted you to apply?

Have you been convicted of a felony?

Yes

Please explain the circumstances of the conviction and when it occured.

Have you been suspended from any school?

Yes

Please explain the school suspension and when it occurred.

Authorization and Signature
I certify that all information in this application is complete and correct, and I understand that the submission of false information is grounds for denial of my application, withdrawal of any offer of acceptance, cancellation of enrollment, or any appropriate disciplinary action. I authorize the College to verify the information I have provided with all the schools I have attended. I agree to notify the proper officials of the institution of any changes in the information I provided.

*Signature (please enter your full name)