Extended Campus Programs

Application for Graduate Admission (Page 1 of 2)

Please complete and sign the following application and return along with your $50 non-refundable application fee and Program Agreement by fax to (800) 504-7618 or by mail to American International College, Attn: Kerry Reiter, Extended Campus Programs, 1000 State St., Box 2B, Springfield, MA 01109.

Ms. Mrs. Miss Mr. Dr.

Last First

Date of Birth ______________

Middle Previous/Maiden Name

__________________________________________________________________________________________ __________________________________________________________________________________________
Street Address Apartment No.

__________________________________________________________________________________________
City State Zip Code

Home Phone (

) _________________

Mobile Phone (
Street Address

) _________________Work Phone (

)_____________
City

Mailing Address (if different from above) ___________________________________________________________

__________________________________________________________________________________________
State Zip Code Telephone Number

E-Mail address ______________________________________ Position/Title ___________________________________ Current Employer ___________________________________ Dates Employed _________________________________
Street Address

_________________________________________________________________________________________
City State Zip Code

LIST ALL COLLEGES AND UNIVERSITIES YOU HAVE ATTENDED

Name of College

City and State

Dates Attended

Degree/Date

Undergraduate Major: ____________________________________________________________ PREVIOUS EMPLOYMENT

Employer Location Dates Employed Job Title

1. ________________________________________________________________________________________________ 2. ________________________________________________________________________________________________ 3. ________________________________________________________________________________________________ Do you hold a valid teaching license/certificate? Yes No If yes, please send a copy.*
*You will not be registered for classes until a valid license is received.

Have you passed the Communication and Literacy MTEL? Yes No If yes, please send a copy of the score sheet. Country of Birth _______________________Citizenship: United States Other: __________________________ Gender: Male Female
Ethnicity: Race and ethnicity unknown For non-Hispanics only:

Nonresident alien Hispanics of any race Asian White Black or African American Two or more races

American Indian or Alaska Native Native Hawaiian or Other Pacific Islander

Transfer Credit Request - (Check only if interested in a transfer credit evaluation) By checking this box, I understand AIC accepts a maximum
of 9 graduate level credits. Course descriptions must be submitted prior to having a transfer credit evaluation completed. No request for transfer credit will be accepted after the student has begun their program.

While a student may begin coursework without a complete admissions file, financial aid is permitted only when all application materials have been received and the student is fully accepted.

Extended Campus Programs

Application for Graduate Admission (Page 2 of 2)

Please answer questions 1-4 to select your location and program:

1. What is your preferred Program Location? Medford Pittsfield Weymouth Worcester Greenfield/Orange Springfield

2. What Degree are you seeking? Please select one: Master of Education Certificate of Advanced Graduate Studies (C.A.G.S.) For those who have earned a Master's Degree Master of Arts (School Guidance & School Adjustment Only) -- Springfield Campus Only 3. What Licensure are you seeking? Please select one: Initial License Professional License - For those who intend to advance their Initial License within the same area of concentration. Degree Only - For those who are not seeking Massachusetts DESE licensure Professional License Only 12 credit hour non-degree program for those who already hold a Master's Degree and intend to advance their license within the same area of concentration. (Professional License available for Early Childhood, Elementary Ed., Moderate Disabilities Pre K-8 only) 4. What Program are you enrolling in? Please select one: Early Childhood Education (Pre K-2) Elementary Education (1-6) Moderate Disabilities (Pre K-8) Moderate Disabilities (5-12) Middle School Education (5-8) not available as Professional License Please circle subject area: Secondary Education (8-12) not available as Professional License Please circle subject area:
Business Biology Chemistry English French Business Biology Chemistry English French History Math Political Science Spanish General Science

Reading (Pre K-12) not available as Professional License - applicants must hold at least an initial level teaching license and have one year teaching experience. School Administration - not available as Professional License; Please circle subject area:
Principal/Assistant Principal (PreK-6 / 5-8 / 9-12) Special Ed Administrator Supervisor / Director (Area/Level: ________________________) Superintendent/Assistant Superintendent

History

Math

Political Science

Spanish

*School Adjustment Counseling (Pre K-12) *School Guidance (Pre K-8) *School Guidance (5-12)
I understand that by signing this application, I will be registered for the first semester of the above selected program and that I remain registered for these 8 week courses unless written notification is submitted to the Office of Extended Campus Programs before the second class of the first 8 week course. I verify that the information provided on this application is true and correct. I understand that the falsification or withholding of any information in regard to this application may result in a loss of credit and dismissal from the institution.

*Offered in Springfield ONLY

Student Signature: _______________________________________________ Date: ____/____/____

Fax to: 800-504-7618: Mail to: American International College Attn: Kerry Reiter Extended Campus Programs 1000 State St., Box 2B, Springfield MA 01109