M.A.T. Application for Admission

Section I: Personal Information
First Name:
Middle Name:
Last Name:
Preferred Name:
Sex:
Address:
City:
State:
Zip:
Home Phone :
Work Phone:
Cell Phone:
Email:
Social Security Number:
Date of Birth :
Country of Birth:
Have you ever attended LaGrange College?
 If yes, when:
Are you a veteran:
 If yes, do you plan to use the G.I. Bill:
Have you ever been convicted of a felony in the United States or been dishonorably discharged from the United States Armed Forces*.
 If yes, please explain:
Indicate the level of certification you wish to obtain:
The following information is requested for statistical purposes to the U.S. Department of Health and Human Services.
Please place a check in front of the proper category or categories.
Your response to this section is voluntary.
Religious preference:
Marital Status:
Certification level(s) of interest:



Content area(s) of interest:







 
Section II: Educational Background: Please list all colleges and universities you have attended.
Institution:
City and State:
Dates Attended:
Degree and Major:
Graduated:
  
Institution:
City and State:
Dates Attended:
Degree and Major:
Graduated:
  
Institution:
City and State:
Dates Attended:
Degree and Major:
Graduated:
  
Section III: References: List the name of the three personal references who will be sending letters of recommendation on your behalf:
Reference 1:
Reference 2:
Reference 3:
  
Section IV: Employment history: List previous work experience:
Employer:
City/State:
Position:
Dates:
  
Employer:
City/State:
Position:
Dates:
  
Employer:
City/State:
Position:
Dates:
  
Section V: Standardized tests: Select all tests you have taken:
GACE Basic Skills Assessment:
Scores: 
 Reading:
Writing:
Math:
Composite:
  
GACE (Exemption):
Scores: 
 SAT Verbal:
SAT Math:
ACT English:
ACT Math:
ACT composite:
GRE Verbal:
GRE Quantitative:
  
GACE Content Assessments:
Score:
 
I certify that the information given on this application is complete and correct to the best of my knowledge, and that I have attended no other institution other than those listed. I understand that I am responsible for the forwarding of records from all schools I have attended, and that such transcripts become the property of LaGrange College and will not be returned to me.