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Application for Admission to
Master of Science in Rehabilitation
Counseling Program
Wilberforce University
Graduate Rehabilitation Counseling
Program
P. O. Box 1001, 1055 N. Bickett Road
Wilberforce, OH 45384
Program Director: (937) 708-5488
Program Admin: (937) 708-5494
http://www.wilberforce.edu
Note: Please print or type in the space provided. Show “N/A” (not applicable) when appropriate.
Please indicate the semester you wish to begin studies:
Fall
Spring
(yyyy)
(yyyy)
Personal information:
Referred to program by:
Name
Last
First
Middle
Suffix (Jr., II, etc.)
Middle
Suffix (Jr., II, etc.)
Previous Name (other name under which your transcripts might appear)
Last
First
Street Address
Apartment
Zip/Postal Code
Country
City
Home Phone
State/Province
Cell Phone
(Area Code) Phone Number
(Area Code) Phone Number
E-mail Address
Student Citizenship:
U.S. Citizen
Resident Alien
Refugee
Student (Exchange visitor)
If you are not a U.S. citizen, please specify the country of citizenship:
, city and country
of birth:
, indicate visa and date of entry into U.S.
Family members who are WU Alumni:
Father
Mother
Brother
Sister
Spouse
Others
Following 4 questions will be kept confidential and will not be used to deny access or admission. This information will, however, assist
the university in providing data to demonstrate compliance with the federal regulations.
Date of birth:
/
/
Gender:
Female
Male
mm / dd / yyyy
Race/Ethnic Group:
American/Indian
Asian
Do you require reasonable academic accommodations?
African American
Yes
Hispanic
White
Other
No
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Academic Information
1. List in chronological order all colleges and universities, including WU, that you have attended. Attach sheet if necessary.
College or University
City/State
Inclusive Dates
Major
Degree/Date
2. Please list any professional or academic award you have received (publication, awards, prizes, or fellowships. Use separate sheet of
paper if necessary).
3. Do you wish to be considered for financial aid?
4. Will you enroll:
Full time
Yes
No
Part time
5. Have you previously applied for graduate admission at Wilberforce University?
6. Please indicate which examination you have taken:
GRE
/
Yes
/
No
Miller
mm/dd/yyyy
/
/
mm/dd/yyyy
Employment Background and Other Information
1. Employed full time currently:
Yes
No
Employed part time currently:
Yes
No
2. Please list your professional work experience. List most recent first.
Employer
Title
City/State
Date of employment
Full time or part time
FT
PT
FT
PT
FT
PT
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Letters of Recommendation
Three letters of recommendation are required. (Please download recommendation letter from website). You are responsible for arranging
to have each person listed above send a letter to: Rehabilitation and Disability Studies Department, Wilberforce University, Wilberforce,
OH 45384. All letters of recommendation will be retained in your student records file and used for the admissions decision along with your
other application documents.
List your Recommenders:
Please list the names and positions of at least three persons, preferably professors or professionals, under whom you have studied or
worked. Letters from relatives are unacceptable.
Name
Position
Address
Phone number/E-mail
Statement of Objectives
Write a paragraph of your study objectives.
Failure to complete, sign, and date will result in your application review being delayed.
I authorize the department/university to verify the information I have provided. I certify that the information on this application is true. I
understand that any misrepresentation of facts on this application, if discovered subsequently, will be cause for refusal of admission,
cancellation of admission, or suspension from the university. By signing this application, I agree to abide by the policies and regulations of
the university.
Applicant Signature:
Date:
Do not write below this line. Office use only.
Interview:
Date Received:
Autobiographical:
Yes
Recommendation Letters:
GRE Score: M
1
V
Status:
2
A
Miller Score:
Yes
Yes
3
Date
Date
Transcript Received:
Application Fee:
No
0
Yes
P
No
A
D
C
International Student: TOEFL
Economical Support:
Yes
T
Date
No
Comments:
No
No
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