MASTERS OF SCIENCE IN ADMINISTRATION (MSA) EXTENDED UNIVERSITY DEGREE PROGRAMS
APPLICANT CHECKLIST
Directions to Applicant: Before mailing your application, please read and check the following points:
Fill out application form completely Transcripts:
One official transcript showing all undergraduate and graduate coursework from each institution attended must be submitted with your application. We would suggest you have all transcripts sent to yourself and submit unopened copies along with your application in one packet.
Application/Evaluation Fee:
If you are applying to a degree or credential program, submit a non-refundable Application Fee of $75.00 with this application payable to “California State University, Bakersfield.”
Three MSA Graduate Reference Forms
No friend for family references will be accepted. All three must be professional with at least one coming from an instructor or supervisor. Reference forms must be submitted in a sealed envelope with the signature of the referee on the back flap.
Resume
Statement of Purpose
Applicants can use the page provided in the application or can attach a type written statement.
Basic Statistics course completed with a “C” or better
CSU, Bakersfield requires that all students have immunization records on file verifying proof of MMR (Measles, Mumps, Rubella) vaccination. Please provide a copy of your MMR vaccination with your application or contact the Health Center (661.654.2394) to discuss your options to meet this requirement. This requirement will not prevent you from being admitted, but it will block you from registering for courses.
Submit all application materials to:
CSUB EXTENDED UNIVERSITY 9001 Stockdale Highway – 30BDC
Bakersfield, CA 93311-1022 ATTN: Admissions/Academic Advisor Admission to the Extended University degree program does not constitute admission to the CSUB Main Campus degree program. Students planning to attend classes on the Main CSUB campus should contact the Extended University Degree Program Admissions/Academic Advisor for more information.
If you have any questions regarding this application, need information concerning the program or program criteria, please feel free to contact us at 661.654.6271.
NONDISCRIMINATION POLICY
EUD does not discriminate on the basis of race, color, national origin, sex, physical handicap, or sexual orientation in the educational programs or activities it conducts. Students admitted with physical, perceptual or learning disabilities will be given necessary accommodations provided that their disability has been verified by the CSUB
Office of Services for students with Disabilities (661.654.3360).
This is an application for: Fall ______ Winter ______
Spring ______ Summer ______
Specify major/program objective: ________________________________________________________
Option, emphasis or concentration (if any): ________________________________________________
Legal name: ________________________________________________________________________
Last First Middle
Other name(s) that may appear on your academic records:
_________________________________________________________________________________
Last First Middle
_________________________________________________________________________________
Last First Middle
Birthdate: ________________________________ Sex: Male Female
Social Security Number: ______________________ CSUB ID# (if applicable): _____________________
Current mailing address: ______________________________________________________________
_________________________________________________________________________________
Permanent address if different from current address: _________________________________________
_________________________________________________________________________________
Phone Number: _________________________ Alt. Phone Number: ______________________
Fax Number: ___________________________ Email: ________________________________
FOR OFFICE USE ONLY
TRANSCRIPTS GWAR REFERENCES RESUME STATEMENT OF PURPOSE OVERALL GPA: __________ LAST 90 GPA: __________
DEGREE: ____________________________________________________________
STATS: ______________________________________________________________
ACCEPTED DENIED ________________________________________________
FOR OFFICE USE ONLY CHECK/M.O. #: _________________
AMOUNT: ____________________
DATE RECEIVED: _______________
PART A1
Country of Citizenship (all must answer): __________________________________________________
Use the options listed below to provide your citizenship code: __________________________________
Y – US Citizen R – Refugee/Asylum F – F Visa (student) J – J Visa N – None of the above I – Immigrant I-551 (“green card”) Date issued: ___________________ (be prepared to submit verification) O – Other visa (specify): ______________________________ Date issued: __________________
If you were born outside the US, what year did you move to the US? _____________________________
Use the options listed below to provide your ethnic identity code: _______________________________
1 – American Indian or Alaskan Native; tribe: ________________________________________________________________
2 – Black, non-Hispanic, including African American 3 – Mexican American, Mexican, Chicano
4 – Other Latino, Spanish- origin, Hispanic 5 – Other Asian
6 – Other Pacific Islander 7 – White
8 – Other 9 – No Response A – Central American B – South American C – Chinese D – Decline to State
F – Filipino G – Guamanian H – Hawaiian J – Japanese K – Korean L – Laotian M – Cambodian N – Samoan P – Puerto Rican Q – Cuban R – Asian Indian
S – Other Southeast Asian
T – Thai V – Vietnamese
List your California County of residence, other US State or Country: ______________________________
Are you a Veteran? Yes No
Print the names and locations of all colleges and universities attended. Begin with the last institution attended.
Attach a separate sheet if you need more space.
School Name State Enrolled:
From – To Degree Awarded:
AA/AS/BA/BS/etc.
Are you eligible to re-enroll at all institutions previously attended? Yes No (if not, please attach explanation)
CERTIFICATION – to be read and signed by all applicants to certify the accuracy of the information provided.
I certify under penalty of perjury under the laws of the State of California and the United States that I have provided complete and accurate responses to the items on this application. I further certify that all official documents submitted in support of this application are authentic and unaltered records that pertain to me. I authorize the California State University to release any information submitted by me in connection with my application to any person, firm, corporation, association, or government agency to verify or explain the information I have provided, to obtain other records necessary for my application, or in connection with perjury proceedings. My signature certifies the accuracy and completeness of the information provided. I understand that any misrepresentation may be cause for denial or cancellation of admission or enrollment.
I certify that so long as I am a student at this institution, I will advise the residence clerk if there is a change in any of the fact affecting my residence.
City and County Applicant’s Signature Date
You are required to include your social security number (or taxpayer identification number) on admission application forms to all CSU campuses pursuant to Section 41201, Title 5, Code of California Regulations and Section 6109 of the Internal Revenue Code. CSU campuses use the social security number to identify your student records maintained in your association with the campus and, if needed, to help collect debts owed the university. Your social security number may be written on your application fee check to facilitate the processing of your fee payment. Also, the Internal Revenue Service requires the university to file information returns that include the student’s social security number and other information such as the amount paid for qualified tuition, related expenses, and interest on educational loans.
That information is used to help determine whether you, or a person claiming you as a dependent, may take a credit or deduction to reduce federal income taxes.
If you do not have a social security number at the time you file the application, you may leave the item blank and the campus will assign a temporary number.
However, you are required to obtain a social security number and submit it to the university by the time you begin enrollment. Failure to furnish your correct social security number may result in the imposition of a penalty by the Internal Revenue Service.
Completion of Part B is required; the information provided below should support the information provided on PART A.
How did you hear about us? CSUB Website Google/Online Search TV or Radio
Social Media Word of Mouth
Other: ______________________________________________
Specify major/program objective: ________________________________________________________
Social Security Number: ______________________ CSUB ID# (if applicable): _____________________
Legal name: ________________________________________________________________________
Last First Middle
Current mailing address: ______________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Phone Number: _________________________ Alt. Phone Number: ______________________
Fax Number: ___________________________ Birthdate: _____________________________
Email: __________________________________________________ Sex: Male Female
Ethnic Identity code as stated in Part A, page 2: _____________________________________________
List below the three faculty members who best know your academic qualifications, including performance, potential, and motivation.
Name Address Position and Institution
STATEMENT OF PURPOSE
Write a brief statement of purpose describing reason(s) for pursuing graduate or postbaccalaureate study.
Include any additional information concerning your preparation which is pertinent to the objective specified.
You may use the page provided or attach a type-written statement.
I certify that the information submitted in this application is true, complete and accurate. I understand that any misrepresentation will be cause for denial of admission.
Signature: ______________________________________________ Date: ____________________
MSA GRADUATE REFERENCE FORM
Applicant: Please complete this section, then deliver or mail this form and self-addressed envelope to your referee. Ask your referee to return the letter to you in the attached envelope with his/her signature across the seal. Do not open the envelope or break the seal. Submit sealed envelope with your application.
Name: _____________________________________________ CSUB ID or SSN: _______________________________
Phone: ______________________________________ Email: ______________________________________________
I understand that this recommendation will be used only for admission and fellowship decisions, and I hereby waive my right of access to this recommendation.
_____________________________________________________ _______________________________________
Signed Date
Respondent: The admissions committee would appreciate your judicious evaluation of the applicant. CSU Bakersfield/Extended University Division uses a self-managed application. To preserve the confidentiality of this recommendation, please affix your signature across the sealed flap of the envelope and return it to the applicant who will submit it with his/her application packet to the CSUB Extended University Admissions Office. If you do not know the student well enough to give a recommendation, please initial here: _____.
ALL REFERENCE FORMS MUST BE PROFESSIONAL (I.E. SUPERVISOR, INSTRUCTOR, ETC.)
Name of Respondent: ______________________________________________ Phone: __________________________
Position/Title: ________________________________________ Organization: __________________________________
How long have you known the applicant? _________________ In what capacity? ________________________________
PLEASE RATE THE APPLICANT ON THE QUALITIES LISTED BELOW:
Truly Exceptional
(top 5%) Outstanding
(top 15%) Above Average
(top 25%) Average
(mid 50%) Below Average (lowest 25%)
Overall
Intellectual Ability
Motivation
Analytical Ability
Ability to work well with others
Ability in oral expression
Ability in written expression
Creativity
Self-Confidence
Leadership
I
strongly recommend,
recommend,
recommend with reservations this applicant for the MSA Program.I
do not recommend this applicant for the MSA program.I
would be willing
would not be willing to respond to additional questions by phone.___________________________________________________ _______________________________________
Signed Date
NONDISCRIMINATION POLICY
EUD does not discriminate on the basis of race, color, national origin, sex, physical handicap, or sexual orientation in the educational programs or activities it conducts.
Students admitted with physical, perceptual or learning disabilities will be given necessary accommodations provided that their disability has been verified by the CSUB Office of Services for students with Disabilities (661.654.3360).
