Section I: Personal Information
First Name:
Middle Name:
Last Name:
Preferred Name:
Sex:		Select Male Female
Address:
City:
State:
Zip:
Home Phone :
Work Phone:
Email:
Social Security Number:
Date of Birth :
Country of Birth:
Have you ever attended LaGrange College?		Select Yes No
	If yes, when:
Are you a veteran:		Select Yes No
	If yes, do you plan to use the G.I. Bill:	Select Yes No
Have you ever been convicted of a DUI or felony in the United States or been dishonorably discharged from the United States Armed Forces*.		Select Yes No
	If yes, please explain:
Indicate the level of certification you wish to obtain:		Select High School Middle Grades
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.		Select Non-resident alien Native American Hispanic African-American Asian or Pacific Islander Caucasian
Religious preference:
Marital Status:		Select Single Married Widowed Divorced
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:		Select Yes No
Scores:
	Reading:
	Writing:
	Math:
	Composite:
GACE (Exemption):		Select Yes No
Scores:
	SAT Verbal:
	SAT Math:
	ACT English:
	ACT Math:
	ACT composite:
	GRE Verbal:
	GRE Quantitative:
GACE Content Assessments :		Select Yes No
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.