Department of Special Education

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					                    Department of Special Education – Doctoral Program
                                   Personal Data Sheet


1. Name:___________________________________________________ 2. Sex: [ ] M                  []F

3. Permanent Address: __________________________________________________________
   City________________________ State _________________________ Zip Code _________

4. Present Address: _____________________________________________________________
   City________________________ State _________________________ Zip Code _________

5. Telephone #: __________________________ 6. Work Phone #:______________________

7. Email: _________________________________ 8. Fax #: ___________________________

9. Birth Date: ___________________

10. U.S. Citizen? [ ] Yes [ ] No             11. Ethnicity: ______________________________

12. MU Student #: _____________________ 13. Anticipated Graduation Date: ____________

14. Degree that interests you:       [ ] Ph.D. (Doctorate of Philosophy)

                                     [ ] Ed.D. (Doctorate of Education)

15. Term and year of expected entrance:      [ ] Winter    [ ] Summer [ ] Fall
                                                    Year:______________

16. Area of Emphasis (Check only one):
 [ ] Behavior Disorders                                 [ ] General Special Education
      [ ] Autism                                             [ ] Autism
 [ ] Early Childhood Special Education                  [ ] Cross-Categorical Special Education
 [ ] Curriculum Development for Exceptional Students    [ ] Learning Disabilities

17.    If you have communicated with, and wish to request a specific advisor,* please give
       his/her name (NOTE: your application will not be processed without prior
       communication with a potential advisor):


________________________________________________________________________
      *Students are encouraged to speak with a faculty advisor about additional requirements
      and/or financial opportunities in the program.
                                    ACADEMIC BACKGROUND
                            (list additional information on a separate sheet)

18. Undergraduate: Major______________________________________________________

       Name & Location of Institution          Dates of Attendance                   Degree

       __________________________             ___________________              __________________

       __________________________             ___________________              __________________

19. Graduate: Major___________________________________________________________

       Name & Location of Institution          Dates of Attendance                   Degree

       __________________________             ____________________             __________________

       __________________________             ____________________             __________________

20. Experience: (list your current to previous experience)

              Employer                           Dates: From/To                      Title/Position

       __________________________             ____________________             __________________

       __________________________             ____________________             __________________

       __________________________             ____________________             __________________

21. Certification
      Are you currently certified to teach?         [ ] Yes           [ ] No
       What is your current certification?          [ ] Provisional       [ ] Life       [ ] Other
       Name of state(s) in which certification is held:__________________________________
       What type of certification do you hold?      [ ] Elementary       [ ] Secondary
                                                    [ ] Other:____________________________
22.    List honorary and professional organizations in which you are an active member (e.g.,
       Phi Delta Kappa, Pi Lambda Theta, MSTA, NEA, etc.):__________________________
       ________________________________________________________________________

23.    List any administrative experience or other activities which reflect organizational
       abilities:_________________________________________________________________
       ________________________________________________________________________
24.   Have you been awarded a scholarship to pursue graduate work? [ ] Yes [ ] No
      If yes, what kind of scholarship is it? For how long is the scholarship? Is it a full or
      partial scholarship?
      ________________________________________________________________________
      ________________________________________________________________________

25.   List any publications that bear your name (you may include reprints).
      ________________________________________________________________________

26.   List any completed research in which you actively participated, even though you may not
      have carried the major responsibility:
      ________________________________________________________________________

27.   Please have an original copy of your GRE scores (and TOEFL, when applicable) sent to
      this office. Applications will not be considered without test scores.

28.   Request three (3) letters of reference using the attached form. The name of the three
      persons are:

      _________________________________________________Email: _________________
      Name                    Position                 Phone: _________________

      _________________________________________________Email: _________________
      Name                    Position                 Phone: _________________

      _________________________________________________Email: _______________
      Name                    Position                 Phone: _______________

29.   Please include on a separate sheet of paper a statement of purpose (usually around 500
      words) in which you summarize your professional goals, including career objectives,
      research interests, your motivation for graduate work, and other pertinent information.




      Mail to:       University of Missouri-Columbia
                     Special Education Graduate Program
                     303 Townsend Hall
                     Columbia, MO 65211-2400



                         An ADA and Equal Opportunity Employer
                                                     Letter of Recommendation

       Name __________________________________________________________________________________________
                   Last Name (Surname/Family Name)                   First Name (Given Name)               Middle Name

       Proposed Degree Program_________________________________________________________________________

       Degree Sought _________________________________________                           Expected Term of Entrance _____________
                                   (Master’s, Ed Spec., Doctorate)
       Under the Family Educational Rights and Privacy Act of 1974, students enrolled at MU have access to their educational
       records, including letters of recommendation on file. Students may waive their right to see letters of recommendation, in
       which case the letters will be held in confidence. If the applicant has not signed a waiver, he or she may request to see the
       letters on file after enrolling in the University.

       I ________________________________________, waive  do not waive  my right to access this form.
        (Signature of applicant)

          1.     Please rank the applicant below by placing an X in the appropriate box next to each characteristic.

               Characteristic                                        Lower     Upper     Upper     Upper    Upper    Unable to
                                                                      50%       50%       25%       10%      5%      Evaluate
               Knowledge in subject of proposed study
               Ability to learn
               Originality, intellectual creativity
               Mathematical ability
               Logical/ analytical ability
               Written expression
               Oral expression
               Laboratory skills
               Perseverance toward goals
               Potential as teacher
               Potential as researcher

      2. Recommendation Summary:                    Recommend with enthusiasm  Recommend
                                                    Recommend with reservations  Do not recommend

     3. Please indicate how long you have known the applicant.
                                           Less than one year                                 One to three years
                                           Three to five years                                 More than five years
     4. Evaluator Information

                 Name: _________________________________________________________________________

                 Title: ______________________________ Employer: __________________________________

                 Address 1: ______________________________________________________________________

                 Address 2:______________________________________________________________________

                 City: _______________________ State: _____________ Country: _________________________

                 Phone: _______________________ Email Address: ____________________________________

                 Relationship to applicant __________________________________________________________

     5. Please provide a candid assessment of the applicant’s accomplishments, strengths and weaknesses, capacity for
     success as a graduate student and/or any other comments on an attached sheet.

Mail to: University of Missouri-Columbia, Special Education Graduate Program, 303 Townsend Hall, Columbia, MO 65211-2400

				
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