Single Sheets - Nyack College

2. PERSONAL INFORMATION continuedList memberships held in honorary and/or professional organizations: ______________________________________________Have you ever been convicted of a crime in the U.S. or in any other country? No Yes (explain on a separate sheet)Have you ever been dismissed from an academic institution? No Yes (explain on a separate sheet)What other graduate schools, if any, are you considering? _______________________________________________________3. ADDRESS INFORMATIONCurrent Mailing Address:Permanent Address (if different than current address)STREET APT #STREET APT #CITY, STATE ZIPCITY, STATE ZIPPHONE: HOME CELL WORKEMAIL ADDRESS4. EDUCATIONAL BACKGROUNDList ALL academic institutions you have attended since high school. You are responsible for having official transcripts sent directlyfrom each institution to the Office of Admissions. Please Note: A preliminary admission decision may be made on the basis of thework you have completed. However, you must have a final transcript showing the conferral of your degree sent to Admissionsbefore being fully accepted.School: ___________________________________________________Degree Received: __________________________________________Dates Attended: ____________________________________________City/State: ________________________________________________Academic Program: _________________________________________Date Graduated: ___________________________________________School: ___________________________________________________Degree Received: __________________________________________Dates Attended: ____________________________________________City/State: ________________________________________________Academic Program: _________________________________________Date Graduated: ___________________________________________School: ___________________________________________________Degree Received: __________________________________________Dates Attended: ____________________________________________City/State: ________________________________________________Academic Program: _________________________________________Date Graduated: ___________________________________________5. CHURCH INFORMATIONNAME OF CHURCH YOU CURRENTLY ATTENDDENOMINATIONADDRESS OF CHURCHHow long have you attended this church?___________________Are you a member? Yes NoHave you confessed Jesus Christ as your Savior and Lord?No Yes If yes, when? _________________CITY, STATE, ZIPPHONE NUMBER OF CHURCHNAME OF PASTORCONTACT PERSON FOR CHURCH

6. HOW DID YOU HEAR ABOUT NYACK?Alumni: __________________________________Faculty: __________________________________Magazine/Newspaper Ad:_________________Other: ___________________________________Parent(s)Pastor: ________________________Student(s): _____________________Radio Ad: _____________________Nyack.edu WebsiteInternetDirect MailingWho/What influenced you to apply? ________________________________________________________________________7. REFERENCESPlease refer to your program application procedures for information about the types of references required. List below the names ofthose you plan to ask for a reference (must be an individual who has known you for one year and is not a relative).Reference: ________________________________________ Phone: __________________________ Email:_________________Reference: ________________________________________ Phone: __________________________ Email:_________________Reference: ________________________________________ Phone: __________________________ Email:_________________8. APPLICANT’S SIGNATURE REQUIREDI affirm that the information set forth in my application and any materials I provide pertaining to my admission and/orfinancial aid are true and complete. I agree that if, in the judgement of Nyack, any misrepresentation or omission has beenmade in this application or related materials, such misrepresentation/omission of information shall be sufficient cause forrejection prior to admission and dismissal if I am admitted as a student.Signature _________________________________________________ Date__________________________________________