Date Taken Total Score

Company

Dates of Employment

Anticipated WorkDo you anticipate working while enrolled?

Anticipated HoursNumber of hours a week you anticipate working (if applicable)

# of Hours Worked Per Week

Your response in the following sections is voluntary and confidential and will only be used for statistical purposes.It ect the status of your application.

Post-undergrad work experienceTotal number of months of work experience, post Bachelor’s Degree

From To

Position

Reading

MCAT Date Score

Date Subject

Date Total ScoreCBEST

CSET

Other Exam

Listening Writing Speaking

I II III IV

Writing Reading Math

Yes No

Yes No

Yes No

Yes No

Yes No

TOEFL

Other Tests

Current or Most Recent Employment

Past and Anticipated Employment

Are you currently serving in the US Armed Forces?

Has either one of your parents received a graduate degree?

Has either one of your parents received an undergraduate degree?

Are you a U.S. Veteran?

Personal Survey

References (list the names of reference providers from whom we can expect letters of recommendation)

Name Title Organization Email Address Phone Number

Please rank the importance of the following characteristics of CGU that you considered in your decision to apply.

(Rank of 1 being most important and 5 being least important.)

CGU faculty or their publication Employer or co-worker Online advertisement

CGU sta! including recruiters CGU website CGU Promotional materials

CGU student or alum Online search Other

Claremont Colleges Member Graduate school reference guide

Faculty member at your institution Print advertisement

The overall reputation of the university

Select one

If selected ‘other’, please specify

Reputation of Faculty

Reputation of the academic department

Location

Flexibility of the curriculum

Personal contact with faculty and/or sta!

Graduate-only institution

Membership in the Claremont Colleges Consortium

Diversity of the student body

Internship/Research Opportunities

Amount of Funding Available

Please list other institutions to which you are applying

Please include with this application the two required supporting documents, the Personal Statement and the Resume/CV. Please ensure that your full name and the name of the academic department to which you are applying is clearly labeled on your document.

If admitted, how important will the availabilityof fellowship aid be in your decision to attend CGU?

Importance Rating

Other Institutions

What to Include in your application?

How did you hear about CGU?

Zip

Emergency Contact Name

Street Address

City

Email Address

Country

Phone Number

State/Province

Emergency Contact Relationship

Emergency Contact Information

Payment Type

Date

Student Signature

Date

Amount

Application Payment

Important Admissions Disclosures

Accuracy of Submissions: Applicants are required to sign a statement at the end of the application form certifying the accuracy of the information submitted. Any misrepresentation may be cause for denial of admission. If misrepresentation is discovered after admission, dismissal from CGU and revoking of any degree granted may result.

Use of Applicant Documentation: All records submitted to the Office of Admissions at CGU become part of a candidate’s official file and can neither be returned nor duplicated for any purpose. It is recommended that candidates obtain copies of their official credentials to keep in their possession. No copies will be provided to third parties outside the University even if the applicant requests this release. Copies will be provided to appropriate offices at the University, however, in the interest of academic matters or financial awards relative to the applicant. Applications and supporting documents are retained according to the retention policies of CGU.

Retention of Applicant Documents: Admissions retains and destroys after 18 months all application materials received from applicants who did not register for courses after admission, who were denied admission, who did not respond to CGU’s offer of admission, and whose application files were never completed.

Credit Card Payment Request Form

Credit Card Payment Request

Card Type VISA MASTER CARD

Card Number

CVV (last three digits at the back of the card)

Name of the Card Holder

Amount of Payment

Card Expiry

Student Information

Student Name

Program Name

Program Start Date

Student Number

Signature Date