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					                                                                               Complete and return this form to:
                                                                               Program Coordinator
                                                                               The Patterson School
                                                                               University of Kentucy
                                                                               455 Patterson Office Tower
                                                                               Lexington, KY 40506-0027 USA


Last Name:                                          First Name:                                     Middle Name:

Gender:           Female         Male         Salutation:                  Preferred Name (nickname) :

Ethnicity:     (Optional; This information will not be used in a discriminatory manner)

   White/Caucasian/not of Hispanic Origin           Native-American/Alaskan native          Mexican-American/Chicano
   African-American/Black                           Puerto Rican                            Hispanic/Latin
   Asian-American/Pacific Islander                  Other:

Social Security Number:                                         E-mail Address:
Current Mailing
Address:

City :                                              State:               Country :                                 Postal-Code:
                                                                                           Country
Phone :                                 Secondary Phone :                                  of Citizenship :
(Home, Daytime, etc.)                   (Cell Phone, Work Phone, etc.)

Permanent Address
( if different from
above):


Fall year for which you are applying:                       Have you applied to the Graduate School and sent your fee?               Yes   No


Have you applied to another program at the University of Kentucky with the intent of studying concurrently?                          Yes   No

If you answered yes to the above, which program:

Are you applying for financial assistance by filling out an application for fellowship?             Yes       No

Institutions attended and degrees awarded (chronological)

Institution:                                         Degree:                 Date            Major                                   GPA

Institution:                                         Degree:                 Date            Major                                   GPA

Institution:                                         Degree:                 Date            Major                                   GPA
(If more than three, please explain below)            (A.S. B.S. etc.)                                                       (On a 4.00 scale)

Additional Graduate Study:

GRE Scores (Score / %)
                                                                                                                      Date of GRE:
Verbal:                      Quantitative:                      Total:                Analytical:
                                                                                                                      Planned Date:
TOEFL Scores (if applicable)
TOEFL Score:                     Date of TOEFL:                     Planned Date:

Relevant Work and Employment

Employer:                                       Position:                             Dates:

Employer:                                       Position:                             Dates:

Employer:                                       Position:                             Dates:
Languages spoken / studied other than English




Professional Experience (Society memberships and any elected offices held)




Academic and professional honors (fellowships, scholarships, awards, grants, etc.)




Relevant research: references for published works




Foreign travel in other countries (place, date, and purpose)




Career interests and goals (general two-sentence summary)




How did you learn about the Patterson School? If from an individual, please state name and position.




                                       Signature                                                   Date

  Please attach your statement of purpose to this application

				
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posted:10/14/2011
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