|
| First Name |
|
| Middle Name |
|
| Last Name |
|
| Date of Birth |
|
| Social Security Number |
-
-
|
| Ethnicity |
|
| Email |
|
| Home Phone |
|
| Cell Phone |
|
| Other Phone |
|
| Mailing address |
|
| City |
|
| State |
|
| Zip Code |
|
| Other name that may appear on records |
|
| Date you can begin program |
|
| Do you intend to apply for financial aid? |
|
| Have you attended HPU in the past? |
|
| *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 |
|
| Current License or Certification |
|
| Category/Level(s) of Certification |
|
| Expiration Date |
|
| Areas of Specialization / Supplemental Certificates / Endorsements (as listed on certification) |
|
| Name and address of last school employed. |
|
| 1-Type of assignment |
|
| 1-Principal's name, phone number and email if available. |
|
| 1-Dates taught |
|
| 1-Reason for leaving |
|
| Name and location of previous school employed |
|
| 2-Type of assignment |
|
| 2-Principal's name, phone number and email if available. |
|
| 2-Dates taught |
|
| 2-Reason for leaving |
|
Please list three references with contact information:
|
| 1-Reference name, title & contact information including email address |
|
| 2-Reference name, title & contact information including email address |
|
| 3-Reference name, title & contact information including email address |
|
| Do you have any physical / mental condition that would prevent you from performing all duties as an instructional leader? |
|
| *If yes, please explain |
|
| 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)? |
|
| *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. |
|
| 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. |
|
| 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. |
|
| 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. |
|
| Date submitted |
|