Graduate Certificate Requirements:
Applicants must have an earned baccalaureate degree from an accredited college or university.

Admission Process:

1. Complete and return this application along with your immunization certificate and a $20 application processing fee (check to be payable to Southern Polytechnic State University).

2. Request an official transcript for your undergraduate degree granting institution be mailed directly to the Admissions Office.

PLEASE TYPE OR PRINT INFORMATION

Social Security Number: _________________________________
Date of Birth: Month: _______________ Day: _____ Year: ________
I wish to attend Southern Polytechnic State University in:
___ Fall Semester of _______
___ Spring Semester of _______
___ Summer Semester of _______

Full Legal Name:

Last Name: _____________________ First: ___________________ Middle: __________________

Former Name (i.e.,maiden): ______________________________ Jr., III, etc. _________________

Street Address: __________________________________________________________________

City: _____________________________ State: _________________ Zip Code: ________________

County of Residence: __________________________ Nation: ______________________

Home Phone: ( _____ ) _______________ Business Phone: ( _____ ) _______________

E-Mail Address (optional): _______________________________________

Who should be notified in case of emergency?

Last Name: _____________________ First: ___________________ Middle: __________________

Day Phone: ( _____ ) _______________ Evening Phone: ( _____ ) _______________

How long have you continuously lived in Georgia? _____ years ____ months

Previous State of Residency: ______________________________

Do you have the following items?

Driver's License: __Yes or __No: Which State? ____ Date of Most Recent Renewal? _________
Vehicle Registration: __Yes or __No: Which State? ____ Date of Most Recent Renewal? _________
Voter Registration: __Yes or __No: Which State? ____ Date of Most Recent Renewal? _________
State Income Tax Return: __Yes or __No: Which State? ____ Date of Most Recent Filing? _________

Where you claimed as a tax dependent by a __ parent or __ guardian or __ spouse last year? ___Yes or ___ No
If yes, name of parent/guardian/spouse _________________________________
(If guardian, please attach guardianship documents.)

State of legal residence of parent/guardian/spouse: _________________ How long? ____________

Sex: ___ Female or ___ Male

Applicants are NOT Required to Report Their "Marital Status" or "Race/Ethnic Origin."

Marital Status: ___Married or ___Single

Race:
(1) ___ White
(2) ___ Black
(3) ___ American Indian or Alaskan Native
(4) ___ Hispanic
(5) ___ Asian or Pacific Islander
(6) ___ Multi-Racial

Note: Southern Polytechnic State University is required to report data on race/ethnic group, sex, and marital status to certain federal /state agencies as those data relate to civil rights compliance.

Nation of Birth: _______________________ Nation of Citizenship: ________________________

Native Language: _______________________ Language of Education: _________________________

If U.S. Citizen: ___ By Birth or ___ Naturalized (date) _______________

If Non-U.S. Citizen: Type of visa held or current status: _______________________________

Permanent resident, alien number: _________________________ Date Issued: _______________

(Attach copy of both sides of your I-94 or permanent resident card)

List below all colleges and universities previously attended (if applicable, list SPSU)

Institution --------------- Location -------------------------- From Mo/Yr to Mo/Yr ------- Degree---

IF NECESSARY, ATTACH ADDITIONAL SHEET

Note: Transcripts must be sent directly to the Admissions Office. Failure to list all colleges previously attended will disqualify you as an applicant.
Former Southern Polytechnic State University students do not have to provide previous college transcripts which were submitted for their initial admission to Southern Polytechnic.

Which Graduate Certificate do you plan to pursue? _____________________________

Have you ever been convicted of a felony? ___ Yes or ___ No
If yes, please attach statement explaining your conviction.

I certify that the information contained in this application is true and correct. I understand that any misrepresentation of information will be sufficient cause for rejection or dismissal.

Signed: ______________________________________________________ Date: _________________

MAIL COMPLETED APPLICATION TO:

Director of Admissions
Southern Polytechnic State University
1100 South Marietta Parkway
Marietta, GA 30060-2896

Or Fax this completed application to: (770) 528-4991.

Southern Polytechnic State University is an affirmative action/equal educational and employment opportunity university and does not discriminate on the basis of sex, religion, race, color, age, disability, or national origin.

Certificate of Immunization for Measles, Mumps, Rubella must be submitted prior to admission deadline.