Master of Public Health Program
Application for Admission
1 / NAME:
Last / First / M.I.
2 / Will you be 100% Online Yes No
Full time 9 or more hours Yes No / Degree sought / MPH Gen MPH-Environmental Health
and/orCertificate(Click on X for selection) / X______Community Health Educ.EpidemiologyEnvironmental HealthEnvironmental Risk Assess.Emer. Prep & Homeland Sec
3
UIN (if you already have one) / Maiden name (if any) / Term of entry / Year of entry
4
Street / City / State / Zip
5
Primary phone number / Alternate phone number / E-Mail (you check often)
6 / List those individuals you have asked to provide a reference for you (acceptable from the referee’s email account directly to ).
Name / Phone (area code and #) / Email
A
B
C
7 / Submit a 300 word ACADEMIC ESSAY answering these three questions.
1)What are the most urgent publichealth problems facing your community today?
2)How will a master’s degree in public health help prepare you to address these problems?
3)Which area of public health specialization appeals most to you?
4)
Please submit this Application Form, Academic Essay (see instructions), and a resumé to:
University of Illinois at Springfield
Department of Public Health
One University Plaza, MS PAC 309
Springfield, IL 62703-5407 / 217-206-6720
Fax 217-206-7807
NOTE:You must also submit the university application and official transcripts to UIS Admissions Office
8 / Please check here if you have or intend to apply for a graduate assistantship.
Please check here if you have or intend to apply for a Graduate Public Service Internship.
Please check here if you seekthe Professional Option trackProfessional Track Option
9 / How did you hear about the UIS Master of Public Health program (check all that apply):
Career fair / Illinois Environmental Health Association Newsletter
Illinois Virtual Campus / Illinois Public Health Association Newsletter
Internet Search / Journal of Environmental Health
On-campus Advertising / University of Illinois Online (UIOL)
Personal recommendation / Other (please specify below)
The University of Illinois at Springfield haa an active equal opportunity admissions program. Rev: 1 January 2013