Accelerated MBA Application
APPLICANT INFORMATION (Please type information in the space provided.) Family (Last Name)
First (Given) Name
Middle Name (if any) Maiden Name (if applies)
SS# Date of Birth (mm/dd/yyyy) 7 Gender: Male Female
City of Birth Country of Birth
Country of Citizenship Marital Status: Single Married
CONTACT INFORMATION
Current Mailing Address
(include city, state, and zip code) (note: all correspondence will be mailed to your Mailing address)
Select if your Permanent address is the same as your mailing address
Permanent Address
(include city, state, and zip code)
Country of Legal Permanent Residence:
(i.e., country where you have legal status that you call home)
Legal Resident: State: If Indiana resident, which county Where have you been living for the past 12 months?
Telephone numbers A. Home Number
U.S. Area code Number
International Country code City Code Number
B. Cell Number
U.S. Area code Number
International Country code City Code Number
C. Work Number
U.S. Area code Number
International Country code City Code Number
Richard T. Doermer School of Business and Management Sciences
MBA Program
(260) 481-6498 [email protected]
Email Address (required) Alternate Email Address
If you wish to keep your address, telephone numbers, and/or email confidential, check below:
Address Telephone Numbers Email Addresses
CITIZENSHIP STATUS (for University)
Y (U.S. Citizen) J (Exchange Visa) F (Student Visa) PR (Permanent Resident) R (Refugee) U (undocumented Alien) Alien Registration Number
ETHNIC INFORMATION (optional)
A (Asian/Pacific Islander) B (African American) H (Hispanic American) I (American Indian/Alaska Native) W (White) X (Other)
EDUCATION DATA
List below all colleges and universities you have attended, both undergraduate and graduate:
Name of Institution City/State/Country
From (month/year)
To
(month/year) Major
Degree and Date Awarded
Did you request official transcripts from ALL institutions be sent to the MBA office? Yes No List any academic honors you received (prizes, scholarships, fellowships, etc.)
Have you been out of school for a year or more since receiving your undergraduate degree? Yes No If yes, please explain your activities:
EDUCATIONAL OBJECTIVE STATEMENT
In the box below, please write an essay of 400-500 words or more indicating your experiences and
achievements which reflect management, leadership, organizational, creativity, maturity, initiative, and
administrative skills. Also, specify your educational and job-related goals as you contemplate beginning
your studies for your MBA degree.
PROFESSIONAL DATA
Work Experience (list most recent position first)
Employer Name and Location Job Title Hours/Week Date Began Date Left
List any memberships in Social, Professional or Civic organizations
How or where did you first hear about the Accelerated MBA program at IPFW?
When would you like to begin the Accelerated MBA program? Fall Year:
ADDITIONAL INFORMATION
Please list the names, titles, and addresses of the individuals writing recommendations on your behalf.
INTERNATIONAL APPLICANTS (ONLY)
Dependants: Will your spouse and/or children come with you on a dependant Visa? Yes No If yes, please list your spouse and children names below
Family Member
Full Name (Last, First, Middle)
Birthdate (Month/Day/
Year)
City and Country of Birth
Country of Citizenship
Country of Legal Permanent Residence
Sex
Spouse Child Child Child
Do you currently hold an immigration status in the United States? Yes No
If yes, please indication your Visa type
Per the United States Immigration, all international students must have sufficient funds to pay for tuition, fees, and personal expenses for the entire duration of study in the United States. Please list your sponsor(s) and their information below, include a financial statement with a letter of support from your sponsor(s).
Sponsor's First Name
Sponsor's Last Name
Relationship to Student
Duration of Sponsorship (in
years)
Amount to be paid per year (in U.S.
dollars)
English Proficiency Testing Information
Is English your native language (language spoken in your home)? Yes No If no, what is your native language?
Which test of English proficiency have you taken or will take?
(if you have taken more than one test, select the one you received the best results.) Date you took or will take an English proficiency test
Total score on English proficiency test
Did you request an office copy sent to the MBA office? Yes No
If no, please request that official test results be sent to the MBA office. (school code for all exams is: 1336)
I CERTIFY THAT ALL INFORMATION ON THIS APPLICATION FORM IS TRUE TO THE BEST OF MY KNOWLEDGE. I understand that withholding information requested on this application or giving false information will make me ineligible for admission or subject to dismissal.
Signature: Date:
Note: Click the signature field and follow the instructions to input your electronic signature. Submitting this application online or via email constitutes an electronic signature.
TO BE USED BY ORIGINATING OFFICE:
Entry Term: Admit Type (GB, GR, GI): Application Fee (P, W):
Program: Student Type (G, N): Initials: Date:
Major: Residency (R, N):
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