OAESA - Online Application

Off-Campus Education Programs

Application Form

Student Information

Salutation: *

Ms.

Mrs.

Miss

Mr.

Last Name *

First Name *

Middle Name

Former-Maiden Name

Street Address *

Street Address 2

City *

State *

Zip Code *

Email *

Birth Month (MM) *

Birth Day (DD) *

Birth Year (YYYY) *

Area Code *

Home Phone *

Area Code *

Cell Phone *

Area Code

Work Phone

Ext

Mailing Address (if different from above)

City

State

Zip Code

Program Selection

Term *

Summer 2024 (May)

Fall 2024 (August)

Type of Degree (Summer 2024): *

Master's Degree

Doctoral Program

Type of Degree (Fall 2024): *

Master's Degree

Doctoral Program

Master's Programs *

MA - School Leadership with Principal Licensure	Principal Licensure Only
MA - Teacher Leader with TL Endorsement	Teacher Leader Endorsement Only
MA - Differentiated Instruction

Doctoral Programs (Summer) *

Doctoral Programs *

Citizenship Information

Country of Birth *

Citizenship *

Citizen

Permanent Resident

Non-citizen

International

Permanent Resident Number:

Visa Type: (H-1, F-1, Other)

Educational Information

Do you hold a valid Ohio teaching license? *

Yes

No

If yes, indicate Type *

License is: *

Years of Teaching Experience

A Standard License is required. If you currently hold an Alternative License, please call the Graduate Information Office at 800-946-9608 for more information.

Do you hold a valid Ohio Principal license? *

Yes

No

License is: *

Years of Administrative Experience (In a role requiring an Administrative License)

Academic History - Please list all schools attended where degrees were earned, and where graduate coursework was completed that you may want considered for transfer credit.

College/University Name *

City 1 *

State 1 *

Zip Code

Degree Title *

Date Started
(MM/DD/YYYY) *

Date Ended
(MM/DD/YYYY)

College/University Name

City 2

State 2

Zip Code

Degree Title

Date Started
(MM/DD/YYYY)

Date Ended
(MM/DD/YYYY)

College/University Name

City 3

State 3

Zip Code

Degree Title

Date Started
(MM/DD/YYYY)

Date Ended
(MM/DD/YYYY)

College/University Name

City

State

Zip Code

Degree Title

Date Started
(MM/DD/YYYY)

Date Ended
(MM/DD/YYYY)

College/University Name

City 4

State 4

Zip Code

Degree Title

Date Started
(MM/DD/YYYY)

Date Ended
(MM/DD/YYYY)

Professional Experience

Employer *

Location *

Job Title *

Date Started
(MM/DD/YYYY) *

Date Ended
(MM/DD/YYYY)

Employer

Location

Job Title

Date Started
(MM/DD/YYYY)

Date Ended
(MM/DD/YYYY)

Employer

Location

Job Title

Date Started
(MM/DD/YYYY)

Date Ended
(MM/DD/YYYY)

Employer

Location

Job Title

Date Started
(MM/DD/YYYY)

Date Ended
(MM/DD/YYYY)

Employer

Location

Job Title

Date Started
(MM/DD/YYYY)

Date Ended
(MM/DD/YYYY)

Have you attended Concordia University Chicago before? *

Yes

No

If yes, indicate year

Military Information - are you (select one) *

Active Duty

Veteran

Military Dependent or Spouse

None

Do you plan to use military benefits at Concordia University Chicago? *

Yes

No

Will you be applying for Financial Aid? *

Yes

No

Confidential: For Statistical Purposes Only

Gender *

Male

Female

Religious Affiliation *

Are you Hispanic or Latino? *

Yes

No

Heritage *

Marital Status *

Do you have any relative(s) who attend(ed) Concordia University Chicago (formerly Concordia University, River Forest)? *

Yes

No

If yes, what relation? *

The Honor Pledge

As a student of Concordia University Chicago and a member of the larger society, I pledge to uphold an academic honor code that supports serving and leading with strong personal integrity. Specifically this includes not cheating or using inappropriate or dishonest means in the completion of academic requirements. This also includes not giving unauthorized assistance to others. I understand that it is my responsibility to comply with this honor system.

I understand that Concordia University's official policies and procedures are published in the Graduate Catalog. I understand and agree that these policies and procedures may be revised during my enrollment at Concordia University Chicago. I agree that I am responsible for reviewing and abiding by these policies and procedures.

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.

Signature *

Date (mm/dd/yyyy) *

Verification *
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