Graduate Admissions

APPLICATION FOR GRADUATE ADMISSION

Applicants are required to supply all requested information and return this application with a one-time, nonrefundable

application fee ($45.00 for domestic applicants/$55.00 for international applicants) to:

Austin Peay State University Graduate Admissions

P.O. Box 4458 Clarksville, TN 37044

Online applications are preferred. To apply online, visit the College of Graduate Studies website at

http://www.apsu.edu/grad-studies/ and click the “Apply for Graduate Admission” link in the upper left corner. Additional

departmental admission requirements may also be found on the College of Graduate Studies website.

PLEASE PRINT CLEARLY 1A. If you are you a current or former APSU student please provide your APSU I.D.

1B. Last four of Social Security Number (for tracking purposes only):_________________________ 2. Name Last First Middle Maiden

3. Permanent address (Local address needed if military or dependent.)

Address: Street/P.O. Box/Apt. # City State Zip Code

County: Home Phone: (__ __)_________ _ Alternate Phone: (_____) ________ 4. Mailing address (Local address needed if military or dependent.)

Address: Street/P.O. Box/Apt. # City State Zip Code

County: Home Phone: (__ __)_________ _ Alternate Phone: (_____) ________

5. Email _____________________

6. Date of birth (mo/day/year) 7. Gender (optional) ____Male ____Female

8. Are you Hispanic/Latino? ____Yes ____No

9. Select one or more races ____Asian ____Native Hawaiian or other Pacific Islander

____American Indian ____Black or African-American

____White ____Alaska Native

10. Citizenship (Please check one):

______ U.S. citizen

______ Permanent Resident: resident alien (RA) #: ________________________ If RA; please submit a copy of your resident alien card.

______ Non resident: Visa status (If applicable): ___________ Country of citizenship: ______________________________________________

Country of birth: _______________________________________________________________________________

A

11. Colleges and universities previously attended. (Please DO NOT abbreviate.) List ALL colleges previously attended, including APSU (Clarksville Campus, Springfield Campus, and Fort Campbell), in chronological order.

Name of Institution City State Degree Earned

(e.g. B.A., B.S.N.)

Dates Attended (mo/year) Name under which transcript will

be issued From To

12. Are you currently enrolled at any of the above institutions? ____Yes ____No

13. If you have not earned your baccalaureate degree, when do you expect to attain it? (Mo/Year) ____________________________

14. Please indicate where and when you will first enroll (check only one)

Austin Peay Clarksville Campus: Year 20____

____Fall (August-December) ____Spring (January-March) ____Maymester (May)

____Summer I (June) ____Summer III (May-July)

Austin Peay Center @ Fort Campbell/Springfield Campus: Year 20____

____Fall I (August-October) ____Fall II (October- December) ____Spring I (January-March)

____Spring II (March-May) ____Summer III (May-July)

15. Entry level (check one)

____First-Time Graduate Student ____Readmit Graduate Student ____Transient Student

____Senior I ____Senior II ____International Student ____Graduate Special/Non-Degree

16. U.S. Residents (Please choose one of the following)

o Do you live in the state of Tennessee? ____Yes ____No

If yes, how long have you lived here? (Please indicate the number of years.) _______________________________________

o Do you live in Allen, Calloway, Christian, Logan, Simpson, Todd, or Trigg counties in Kentucky? ____Yes ____No

If yes, how long have you lived there? (Please indicate the number of years.) ______________________________________

o Fort Campbell military personnel claiming exemption from out-of-state tuition must provide Military Unit Address.

Military Unit Address: ____________________________________________________________________________________________________

o Military family members must provide all of the information below.

Name of Sponsor: _______________________________________________ Relationship to Sponsor: ____________________________

Military Unit Address: __________________________________________ Base: __________________________________________________

17. Please indicate your intended degree (Please select one program and, if applicable, one concentration)

Biology (MS) Communication Arts (MA)

Media Management Marketing Communication

Computer Science & Quantitative Methods (MS/PSM)

Data Management & Analysis Predictive Analytics Information Assurance & Security Mathematical Finance Math Instruction (MS only)

Counseling (MS) Clinical Mental Health School Counseling

Curriculum and Instruction (MAED) Advanced Studies Instructional Technology Math

Educational Leadership Studies(MAED) Educational Specialist (EDS)

Administration and Supervision Elementary Education Secondary Education School Counseling

Engineering Technology (MSET) English (MA) Health Care Administration (MHA) Health and Human Performance (MS)

Performance Enhancement & Coaching Public Health Education Sport and Wellness Leadership

Industrial-Organizational Psychology (MSIO) Management (MS) History (MA) Music (MMU)

Music Education Music Performance

Nursing (MSN) Family Nurse Practicioner Nursing Administration Nursing Education

Professional Studies (MPS) Strategic Leadership

Reading (MAED) Social Work (MSW) Teaching (MAT)

Elementary Education Secondary Education Special Education

Certificate (graduate special/non-degree) Community & Organizational Leadership Data Science Certificate Post-Baccalaureate Certificate in Classics Post Master’s Family Nurse Practitioner Post Master’s Nursing Administration Post Master’s Nursing Eduction Post-Baccalaureate Certificate in Classics

18. Selective Service Registration (For US residents only)

Consistent with the federal Military Selective Service Act, Tennessee law requires all male applicants to be registered with the

Selective Service (or certify exemption from the registration requirement) prior to enrolling in state colleges and universities.

You must certify compliance in Section 1 below or indicate the basis upon which you claim exemption in Section 2. For

more information, please go to www.sss.gov.

1. I certify that I am registered with the Selective Service System as required by law. ____Yes ____No

2. I certify that I am not required to be registered with the Selective Service System because:

____I am female ____I am a current member of the Armed Forces on active duty

____I am younger than 18 years of age ____I was born before 1960

____I am an exempt Resident Alien ____Other (please specify) _______________________________________________

19. Active duty/Veterans/Family Members (For US residents only)

If you are active duty, an AARTS, SMART, DD295, or CCAF transcript is required. If you are a veteran, a DD Form 214 Member

Copy 4 is required.

Status (check one): Active Duty ____ Family Member ____ Veteran____ Retired Veteran ____

Date entered armed services: ______/________ Date separated: ______/________ Military I.D. expiration date: ______/________

Active Duty Use Only (Family Members/Retirees do not complete):

Pay Grade ___________________ Unit Address ___________________________________________________________________________________________

Military Base ________________________________________ State __________ Unit Phone ______________________________ Years of Service _________

20. Professional work experience. Please indicate the number of years of professional work experience you have using a

whole number ranging from 0 to 50. _________________________

21. How did you learn about APSU’s College of Graduate Studies?

Billboard

Friend or Family Member

Newspaper

Fort Campbell Education Center

I am a current APSU student

Internet (please specify): _________________________________

APSU Contact (please specify):___________________________

Petersons.com

Other (please specify):____________________________________

I understand that withholding information requested on this application, including attendance at any other institution,

or giving false information may make me ineligible for admission to the college or subject to dismissal. I have read this

application and certify that the statements I have made on this application are correct and complete, including a report

of all college work attempted or completed.

In addition to the forgoing, the Tennessee Eligibility Verification for Entitlements Act requires an applicant for in-state

tuition or state financial aid to attest under the penalty of perjury that he or she is either a United State citizen or alien

lawfully present in the United States. By submitting this application, I am attesting that I am either a United State citizen

or alien lawfully present in the United States or I am not requesting any state benefits including in-state tuition.

I understand that this attestation is required by Tennessee law if I have applied for a state public benefit. I understand

that Tennessee law requires me to provide documentation verifying the status indicated above prior to receipt of this state

public benefit. I understand that knowingly and willfully making a false, fictitious, or fraudulent statement or

representation shall subject me to liability under the Tennessee False Claims Act, Tennessee code Annotated 4-18-101 et

seq. I understand that if I am found to have made a false or misleading statement my state public benefit may be rescinded

or I may be disciplined by Austin Peay State University.

By my signature, I certify that the information supplied on this form is complete and true. If accepted, I agree to abide by

all APSU rules and regulations as printed in the Code of Student Conduct, Graduate Bulletin and other University

publications. I also understand the application fee is nonrefundable.

Signature: ____________________________________________________________________________________________ Date: __________________________________

Information for students with disability

If you have a learning or physical disability and want information on types of services and support that are available, please

contact the Office of Disability Services at (931) 221-6230 voice, (931) 221-6278 TTY. It is recommended that students who

many benefit from these services make early contact with the office so that appropriate accommodations can be arranged.

Please submit your completed application and application fee

($45.00 for domestic applicants/$55.00 for international applicants) to:

APSU Graduate Admissions, P.O. Box 4458, Clarksville, TN 37044

Austin Peay State University does not discriminate on the basis of race, color, national origin, sex, disability or age. Austin Peay State University is an AA/EEO

employer. AP687/4-11/50 Y:\New Forms\Admissions Forms\ApplicationforGraduateAdmission080816.docx