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Application for Admission

Application Date:

July 8, 2008

* = Required Information

* Program:

Ph.D.
Ph.D./J.D.
Distance Learning M.S.
Ph.D./MBA
Forensices
Neuropsychology

* Term:

Personal Information:

* First Name:

* Middle Name:

* Last Name:

Names on records from previous schools:

* Social Security Number

Current Contact Information:

* Street:

* City:

* State:

* Zip:

* Home Phone:

* Work Phone:

* Fax:

* E-Mail:

Permanent Address (if different)

Street:

City:

State:

Zip:

Country of Citizenship:

Alien Registration Number:

Visa Number:

The information below is optional. It is requested for statistical purposes only and will be kept confidential.

Date of Birth (mm/dd/yyyy):

Gender:

Not Specified
Male
Female

Ethnicity:

Not Specified
Alaskan Native or American Indian
Asian or Pacific Islander
Hispanic
African-American
Caucasian
Other (specify)

Physical or Learning Disabilities:

Not Specified
No
Yes

If Yes, please describe what, if any needs you may have:

Educational Background

List all colleges attended since high school and all degrees conferred. If you do not have a degree, indicate the total number of units completed at each college. If you are currently working towards a degree, please indicate the degree you expect to earn,and the expected date, in parentheses. If you participated in an exchange program while attending one of the listed institutions, please do not list that program separately.

Institution	State or Country	Dates Attended (From/To)	Major	Degree (or units)	Date Degree Received

Graduate Record Exam

All Ph.D. applicants must take the general Graduate Record Exam (GRE) and have an official score report sent to PGSP. The PGSP institution code for the GRE is "4638."

I have taken the GRE on I will take the GRE on (Provide Date)

Professional Interests

While you will discuss these items in greater detail in your professional statement, please summarize the following information:

Potential area of concentration during clinical training:

Potential area of concentration in research studies:

Recommendations

Please list below the names and addresses of the three persons from whom you have requested a recommendation. These references should be able to speak to your ability and/or potential for both research and clinical work. Whenever possible they should be faculty members in psychology or practicing professional in psychology.

Name	Title	Address/City/Sate/Zip

I understand that official transcripts of credit earned at other institutions and other documents which have been presented for admission or evaluation become the property of PGSP and are not returned to the applicant.

I certify that the information recorded in this application, the transcripts provided, and all other application materials submitted are correct and complete. By submitting this application, I agree to abide by and be subject to the rules and regulations at PGSP.

Applicant's Signature: _______________________________________

Date: ________________