Personal data form by 2mz1O10


									Personal Data Form                                                                    Rev. 08/10

                          MILLERSVILLE UNIVERSITY
                        MILLERSVILLE, PENNSYLVANIA

 The Personal Data Form is a multi-purpose form for use in student advisement, acceptance into the social
  work program and for field/community service placements in the junior and senior year. Therefore, it is
  important that the form be filled out as accurately and completely as possible. If you have any questions
 about this form, please discuss it with your faculty adviser. A copy of this document will go to the social
                   agency when the student goes into interviews for senior field placement.

(Please type and save so that you can make updates as appropriate)

1.   Name:
                     Last                                First                            M.I.

2.   MU Student Identification Number:

3.   Your Address while attending college (including zip code):

4.   Your Phone # while attending college:

5.   Cell Phone #:

6.   Millersville Email Address:

7.   Home/Permanent Address (including zip code) if different than above :

8.   Home/Permanent Phone # (if different than above):

9.   Fluency in a foreign language:     Y         N        (which one?)

10. Driver's license? Y                 N

11. Education: (please answer under each of the items)
     Colleges attended         Dates (from-to)           Expected Graduation Date          Major          Minor

12. Social Work Elective Courses completed or in progress:

13. Most recent date that clearances were submitted:
                      Child Abuse       FBI                                      PA Criminal
Personal Data Form                                                                    Rev. 08/10

14.     Employment Information: (Include all work experience, full-time or part-time, and military
        Name of Employer                     Description of Work                          Dates Employed

15.     Volunteer and field work: (Please list your most recent first)
        Agency                           Description of Work                      Hours            Dates

16.     Fall 2010 Semester Schedule of Classes:

17.     Current and future social work interests:

*If there are any changes in these items please notify the Social Work Department.

(**) Please note that this form will be attached to your final Professional Statement/Self Awareness Essay for
the Screening and Selection review process and will be kept in your departmental file.

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