Educational Technology Policy, Research, & Outreach

Applicant Information

First Name:         
Middle Name:        
Last Name:          
Social Security #:  

Street Address:     
City:               
State:              
Zip Code:           

*Please include your area code
*Home Phone:        
*Work Phone:        
E-mail:             
URL:                

Citizenship:  US	Other:
Date of Birth(m/d/yr):
Gender:  Male   Female 

*The information below is requested for the purpose of 
 determining compliance with federal civil rights laws.  
 Completion is optional.

*Ethnicity:
            

American Indian/Alaskan Native

Black, not of Hispanic Origin

Asian or Pacific Islander

Hispanic

White, not of Hispanic Origin

Other

Do you have an Undergraduate Degree from an accredited institution?
Yes  No
(This is a requirement for admission and registration for this class.  If you DO NOT have an undergraduate degree, you will not be permitted to continue with this application process.)

List all previous institutions you have attended, dates and degrees awarded:

Institution 1:     
Dates and Degrees: 

Institution 2:     
Dates and Degrees: 

Institution 3:     
Dates and Degrees: 

Have you ever been admitted to the Graduate School of the University of Maryland College Park before?
Yes           No           Current Student
If Yes, Dates of attendance: Degree earned:

Note: Responses to the following questions are REQUIRED for processing of your application.

    1. Has disciplinary action been taken against you at any of the institutions you have attended, including the University of Maryland?  (if yes, you must send a separate statement describing the incident and its resolution with this form) Yes    No

    2.Have you ever been indicted for, pleaded guilty to, or been found guilty of any criminal offense excluding minor traffic violations? (if yes, you must send a separate statement describing the incident and its resolution with this form)  Yes    No

Course Information:

Course Number: 

Course Section Number: 

Course Location: 

Date of Course 1st Module: 

I will be sending a check in the amount of $289, made out to the "University of Maryland".   (REMEMBER to write your SS# on your check!)

Please call me at this phone number to get my credit card information.

*Please include your area code
*Phone Number:  
Best time to call:  

I will fax my credit card information to you at 301-314-9278.

If faxing your credit card information, the following items are needed:

1. Your name and SS#
2. Name of the cardholder if different from yourself
3. Type of credit card --Visa, Master Card, Discover
4. Amount you are authorizing for payment ($289)
5. Date of expiration
6. Credit card number
7. Your signature
8. Course number, section number, and start date

Please bill my employer/agency at the address below:

(A copy of this "approval to pay" must be attached or on file at the University Office)

Agency Name:

Contact Person: 

Street:  

City/State/Zip:     ,

SIGNATURE:    (Signature Statement is Mandatory for processing.)

Upon entering my name below, I certify that the information on this application is complete and correct.  If it is not, I understand that cancellation of admission and registration may result.  I agree to abide by the rules, policies, and regulations of the University of Maryland at College Park, including the following Honor Statement:

"By establishment of a Student Honor  Council, the University of Maryland at College Park entrusts students with responsibility for promoting the highest standards of academic integrity.  I understand and affirm my commitment to those standards, as specified in the University's Code of Academic Integrity."  Click here to access the complete code:  http://www.inform.umd.edu/jpo/code_acinteg.html

Signature (name) of applicant: 

Date of signature: (m/d/yr) 

Form Submission