Master of Science Program
APPLICATION FOR ADMISSION
WILKES-BARRE, PENNSYLVANIA 18711
(570) 208-5991 FAX (570) 208-8027 ______
Date received (FOR OFFICIAL USE)
Application fee of $35.00 required (non-refundable)
To be printed orName: ______
typed by the First Middle (maiden) Last
Applicant
(continued on Present Mailing Address:______
next page) Number and street
______
City StateZip Telephone
Permanent Mailing Address: ______
(if different from above) Number and street
______
City StateZip Telephone
Email Address:______
Social Security Number (U.S. citizens only): ______
Date of Birth: ______Male: ______Female: ______
Citizenship:
___ United States___ Student Visa___ Permanent Resident
___ Other (specify)___ Other Visa Status (specify)
______
Ethnic background (Please check only one.)
Are you Hispanic or Latino? ❑ Yes ❑ No
What is your racial background? (Please check one or more.)
❑ American Indian or Alaska Native
❑ Black or African-American
❑ Asian
❑ Native Hawaiian or Other Pacific Islander
❑ White
______
Degree ProgramI am seeking admission to the following program:
___ M.S. in Health Care Administration ___ Graduate certificate in Health Care Administration
Year I wish to begin the Program: ______Semester: Spring ____ Fall ____
Post-SecondaryList in chronological order all post-secondary institutions attended. If you are now attending college,
Educationindicate degree you expect to receive and probable date of graduation.
Undergraduate Colleges:
NameDates of Attendance Degree and Date Received
______
______
In what field is your undergraduate degree? ______
Major: ______Minor: ______
Graduate and professional schools:
Name Dates of Attendance Degree and Date Received
______
______
______
AchievementsList in order of importance to you, significant college or community achievements and/or professional
activities in which you have participated.
Achievement/ActivityDatesPrizes, Honors, or Office(s) held
______
______
For International Students
English Proficiency: TOEFL: ______IELTS:______
ScoreScore
______
RecommendationsPlease list two individuals you will be contacting to provide recommendations.
1. Name: ______School/Firm: ______
2. Name: ______School/Firm: ______
______
______
Signature Date
______
Checklist_____ Have you filled out this form completely, enclosed your $35 application Please return application to:
fee, and signed it?
_____ Have you sent your transcripts? King’s College Graduate Division
_____ Have you arranged for your two letters of recommendation to be sent? 133 N. River Street
_____ If English is not your native language, have you taken the TOEFL or IELTS Wilkes-Barre, PA 18711
exam and had the score reported to King's?
_____ Have you filled out and sent a Financial Verification Form?
_____ Have you enclosed a Personal Statement of Interest (maximum two pages)?
(Rev. 12/13)