Application For Admission - Purdue University Calumet

Graduate School
Application For Admission
www.calumet.purdue.edu/gradschool/
______________________________________________________________________________________
Purdue University Calumet is an equal access/equal opportunity university
1. Name _________________________________________________________________________________________________
Last First Middle
2. Social Security# _____________________________________ 3. Date of Birth: ______________________________________________
(Month) (Day) (Year)
4. Gender: Male______ Female______ 5. Marital Status: Single______ Married______
6. Home Address: _________________________________________________________________________________________________
Number & Street City State Zip Country
7. State of Residence for the past 2 years _______________________________________________________________________________
Street City State Country
ENTRY DATE: SPRING 200____ (JANUARY) FALL 200_____ (AUGUST) SUMMER 200___ (MAY/JUNE)
8. Home Phone (______)___________________9. Work Phone (____)_____________________10. Email______________________
11. Cell Phone or Pager (_____)_______________________12. International Phone (______)___________________________________
13. U.S. Citizens-state or county code________________ Permanent Residents-state code and citizenship number__________________
(Use codes shown on attachment)
14. U.S. Citizen: Yes_______ No_______ 15. Visa Type: _____F1 _____J1 _____Other _____(specify)
16. Alien Registration #______________________________ 17. Country of Birth________________________________________
State and Federal laws pertaining to civil rights require the University to report ethnic data. U.S.Citizens and
permanent residents only.
18. Ethnic Data ____ A=American Indian ____B=White/Non Hispanic ____C=Black/Non Hispanic
____ D=Asian or Pacific Islander ____S=Hispanic ____E=Other
19. Entry Status ____Current or former Purdue Graduate ____ Never previously enrolled at Purdue
____ Current graduate student transferring campuses ____Former Purdue graduate student re-entering
____ Current or former nondegree graduate student to be reclassified as degree seeking
20. Enrollment Objective _____Master’s Degree _____Teacher license_____Postbaccalaureate_____Certificate Program
21. Department Code ______________ (see insert for listing of codes) Must list specific program/major, i.e. MBAE
Major________________________________Minor______________________________(Required for Education majors)
22. Test Scores: GRE________ GMAT_________ TOEFL_________ Date of Test Month/Year___________________________________
2200 169th Street • Hammond IN 46323-2094 • (219) 989-2257 • FAX: (219) 989-2581

Institution
City & State_______Dates From/To_____Degree & Date____ Major________GPA__________________
23.College
Experience
1._________________________________________________________________________________________________
2._________________________________________________________________________________________________
Employer_________________________Position___________________From/To_____________Type of Work_____________________
24. Employment 1.__________________________________________________________________________________________________
Experience
2.__________________________________________________________________________________________________
3._________________________________________________________________________________________________
25. Recommendations Names of three persons sending letters of recommendation directly to the department to which you are applying
(DEGREE SEEKING ONLY)
1.____________________________ 2.________________________________ 3._________________________________
26. In Emergency Person to notify: Name____________________________________________Telephone___________________________
Address___________________________________________________________________________________________
Your fee payment (Degree Seeking Only) must accompany your completed original application form (Copies not accepted).
I certify that the information provided on this application is accurate and complete. I understand that falsified information
may result in denial of admission and/or termination of enrollment at Purdue University. I certify that I have not been
censured for academic dishonesty during my previous college enrollments. If I have been, I will provide an accompanying
explanation.
27. Signature _____________________________________________________ Date of Signature_____________________
(Required)
To Be Completed By Department
ADMISSION RECOMMENDATION
________Approved
________Denied
FEE PAID
_________ Date
Approved With The Following Conditions(s):
____Maintain_____ graduate index for the first___________ hours of graduate level credits
____ No grade below “B” for the next________________credits
____Complete_____ credits minimum first session Other__________________________________________________________
____________________________________________ _________________ ____________________
Signature of head of the graduate program or designee Date Dept. code
______________________________________________________________________ ________________________________________
Adviser (please print)
Graduate Faculty Identifier
For Graduate School Use Only
Conditions ____Demonstrate English Proficiency ____Submit final transcripts showing previous degrees awarded
____ Complete degree expected
____ Other__________________________________________________________________________________________________
Graduate School Approval___________________________
2200 169th Street • Hammond IN 46323-2094 • (219) 989-2257 • FAX: (219) 989-2581

2200 169th Street • Hammond IN 46323-2094 • (219) 989-2257 • FAX: (219) 989-2581