Master of Education in Instructional Leadership Application Howard Payne UniversityCampus OfficesAdmissionsApplyMaster of Education in Instructional Leadership Application Personal Information Fields in red are required. First Name * Middle Name Last Name * Maiden Name/Name Used if Previously Enrolled at HPU E-mail * Phone * Alternate Phone Address * City * State * Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Code * Ethnicity American Indian or Alaska Native Asian Black or African American Hispanic Native Hawaiian or other Pacific Islander White Two or More Races Other Other name that may appear on records Enrollment Information Date you can begin program? * Do you plan to apply for financial aid? * Yes No Education Have you attended HPU in the past? * Yes No If yes, provide dates of attendance. Name and location of college(s) attended * Course of study and major/minor * Diploma, degree, certificate, or license granted * Year graduated college * Certification and Employment Information Current License or Certification * Valid Texas Teacher Certification Texas One-Year (out-of-state/country) Valid Other State Other None Category/Level(s) of Certification Expiration Date Certification Route * Traditional Alternative If you chose "Alternative Certification" please indicate the name of the program. Areas of Specialization / Supplemental Certificates / Endorsements (as listed on certification) Name and address of last school employed Type of assignment Principal's name, phone number and email if available. Dates taught Reason for leaving Name and location of previous school employed Type of assignment Principal's name, phone number and email if available. Dates taught Reason for leaving References Reference name, title & contact information including email address * Reference name, title & contact information including email address * Reference name, title & contact information including email address * I authorize the references provided in this application to give any and all information concerning my character and any pertinent information they may have, personal or otherwise, and release all such parties from liability for any damage that may result from furnishing the same to Howard Payne University. * Yes No Other Information Do you have any physical/mental condition that would prevent you from performing all duties as an instructional leader? * Yes No If yes, please explain. I understand that the university may review criminal history of applicant. This application becomes the property of the university. The university reserves the right to accept or reject this application verified & affirmation accepted. * Yes No I hereby affirm that all information provided in this application is true and accurate to the best of my knowledge and understand that any deliberate falsifications, misrepresentations, or omissions of fact may be grounds for rejection of my application or dismissal from subsequent admission. * Yes No Have you ever been convicted of, pled guilty or no contest to, or received probation, suspension, or deferred adjudication for a felony or any offense involving moral turpitude (including, but not limited to, theft, rape, murder, swindling, and indecency with a minor)? * Yes No If yes, please state where, when and the nature of the offense. A felony conviction is not an automatic bar to admission. The university will consider the nature, date, and relationship between the offense and the duties of an instructional leader.