Application - Counseling

Date that you wish to begin your studies:
Fall (August)	Spring (January)	Summer (May)	20
Expected Date of Enrollment?
Admission Status:
Full-Time or	Part-Time	Degree seeking or	non-degree
Track:
Mental Health
School Counseling
Marriage and Family

Personal Information
First Name:
Middle Name:
Last Name:
Permanent Home Mailing Address:
City:
Province/State:
Zip:
Telephone:	( )-
Current Mailing Address (College or Temporary Address):
City:
Province/State:
Zip:
Telephone:	( )-
Email:
Where should your mail be sent?	Home Temporary Address
Citizenship:	U.S. Other (Designate Country)
Please check one of the following (optional):
Native American African American Asian American	Hispanic American Caucasion/White American Other
Birthdate:	month day year
Soc. Sec. No.
Church Affliation/Denomination:
Have you ever been a student of Geneva College (either at the main campus or a community location)?	Yes No
If yes, under what name?
How did you hear about the program?
If other, please specify:
Education Background
List all colleges, universities and graduate or professional schools attended. Supply official transcripts for all institutions indicated.
Name of College/University
Starting Date	month year
Graduation Date	month year
Degree Earned
Major

Name of College/University
Graduation Date	month year
Degree Earned
Major

Name of College/University
Graduation Date	month year
Degree Earned
Major
Honors/Activities/Publications

Employment - List all significant work experience beginning with the most recent job.
Employer/Organization:
Job Title/Position:
Dates

Employer/Organization:
Job Title/Position:
Dates:

Employer/Organization:
Job Title/Position:
Dates:

Employer/Organization:
Job Title/Position:
Dates:

Employer/Organization
Job Title/Position:
Dates:

Other Professional Experience

If there are gaps in time in which you were not employed or did not attend school, please account for these gaps:

Names of people doing recommendations: Ask three people, not related to you, who are familiar with your previous academic or professional work to complete and return evaluation reports to the graduate psychology office. These form can be printed from this site. List the persons who will be completing these reports.
Name:	Address:
Name:	Address:
Name:	Address:
I affirm that the information I have provided on this application form and all other admission application materials is complete, accurate, and true to the best of my knowlege. I understand that furnishing false or incomplete information on any part of this admission application material may result in cancellation of admission or registration, or both.
Signature
Date