First Name Last Name Middle Initial. Preferred Name Country of Citizenship* Street Address City State Zipcode

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1 CHRISTIAN BROTHERS UNIVERSITY APPLICATION TO THE MASTER OF EDUCATION PROGRAM FOR TEACHERS WHO LEAD AND LEADERS WHO SERVE please type or print your responses APPLICANT INFORMATION First Name Last Name Middle Initial Preferred Name Country of Citizenship* Street Address City State Zipcode Social Security # - - Date of Birth Veteran? Yes No Home Phone ( ) Work Phone ( ) Cell Phone ( ) Best day/time to call me: This is my personal work school address. *International applicants may have additional required items. Please contact the Department of Education. EMERGENCY CONTACT INFORMATION (Person to contact in case of emergency) Name Emergency Contact Phone ( ) Relationship to you EMPLOYER INFORMATION Employer (please specify school, if applicable) Employer Address City State Zipcode Employer Phone ( ) Supervisor Grade level taught (if applicable) Subject taught (if applicable) ALL COLLEGES/UNIVERSITIES ATTENDED Please list ALL COLLEGES/UNIVERSITIES attended not just where you received a degree. All applicants must meet GPA requirements for their program. Please see the application checklist for more information. Example Name of college/university State University Location City, State Dates Attended From Month/Year Aug/2000 To Month/Year May/2004_ Major English Degree Earned B.A. Office Use Only: Program MASTER EDUC; Degree MED; Major MED

2 Are there any other names (maiden or otherwise) that may be on your transcripts? Yes No If so, please list: PROFESSIONAL EXPERIENCE (current position first) School/Firm Title/Position Dates of Employment School/Firm Title/Position Dates of Employment School/Firm Title/Position Dates of Employment TEACHING LICENSES (please submit copies of any teaching permits or licenses held, including transitional licenses) CONFIRMATION OF GOAL The Master of Education (M.Ed.) degree program is designed for individuals who have already completed initial teaching licensure and who are seeking advanced professional development. It may also be an appropriate program for some individuals who are not working in regular classroom settings but who are involved professionally in the work of educating others (corporate training, community colleges, nonprofit organizations, and other roles); applicants in this situation should seek advising from the Program Coordinator before application. I understand that this application is specifically for admission into the Master of Education (M.Ed.) degree program, which is designed for advanced professional development for teachers and other educators and not for initial teaching licensure. If my situation does not match this, I will seek advising in the Department of Education about my other options and alternatives. Signature Date

3 If your personal situation does not match the intent of the M.Ed. degree program, please describe your situation below: ENTRY TERM January (Spring) June (Summer) August (Fall) March (Spring, mid-semester) July (Summer, mid-semester) October (Fall, mid-semester) (Please be advised that entry in March, July, or October is an opportunity to get ahead on coursework. However - because of the distribution of core course requirements leading to the Capstone Project - March, July or October entry will not mean that students will able to graduate any earlier than students who enter in June, August, or January, respectively.) OPTIONAL ADDITIONAL ENDORSEMENT THAT YOU WISH TO OBTAIN (Check all that apply) Early Childhood Education (PreK-3) Elementary Education (K-6) Middle Grades Education (4-8) Biology (7-12) Mathematics (7-12) Chemistry (7-12) Physics (7-12) English (7-12) Spanish (PreK-12) French (PreK-12) German (PreK-12) History (7-12) Visual Arts (K-12) Special Education Modified (K-12) Reading Specialist (PreK-12)* Other, please specify: * Candidates must accrue three years of teaching experience before submitting an application to the TN Department of Education for Reading Specialist additional endorsement. ACADEMIC BACKGROUND Through what college/university/organization did you fulfill requirements for your initial teaching license? At what level did you complete requirements for your initial teaching license? Undergraduate Graduate Mixture Have you already completed coursework that constitutes advanced professional development in professional educational studies beyond initial teaching licensure? Yes No If so, how many courses of Advanced Professional Development Coursework in Professional Education have you completed? courses courses STATUS OF ADMISSION TEST SCORES All applicants must meet admissions testing score requirements or meet one of the exemption criteria below. Please see the application checklist for more information, including minimum score requirements. Official score reports must be received by CBU. Check this box if you are exempt from admissions testing because at this time you have passed all Praxis II tests required for licensure and your grade point average for the professional studies portion of your program of initial licensure was 3.0 or higher on a 4.0 scale and you will, at the time of your enrollment, hold a valid apprentice/professional teaching license in the state of Tennessee.

4 Check this box if you are exempt from admissions testing because you have currently passed all Praxis II tests required for licensure and you are a current participant in either Teach for America or Memphis Teaching Fellows. If you are not exempt, which accepted admissions test have you taken/will you be taking? GRE Miller Analogies Test If you are not exempt, choose one: I have already taken the test and have met the score requirement. I will be taking the test on (date). I have taken the test, but plan to re-take it on (date). PERSONAL STATEMENT OF MORAL CHARACTER I hereby verify that I have not been convicted of a felony. I further attest that I am committed to a high standard of personal and professional ethical conduct. VERIFICATION OF AUTHENTICITY OF APPLICATION MATERIALS I hereby verify that any essays and statements, as well as any other records that I have submitted to Christian Brothers University as part of my application to the Graduate Education Program are my own and are not the work of another individual. RELEASE OF INFORMATION I hereby give Christian Brothers University full and free access to any and all information contained in my educational, employment, or other records, both past and current. By signing this release, I am granting permission to Christian Brothers University to consult with previous faculty members, university supervisors, cooperating teachers, former employers, and past and present colleagues about my suitability for a career in teaching. By signing this release, I agree to divulge to my Program Director any investigations into my competence in teaching made by Mentor/Cooperating Teachers, Supervisors, or School Administrators. I am also granting permission to Christian Brothers University to conduct a background check. By signing this release, I agree to divulge any ethical or criminal investigations, charges, or convictions to my Program Director from my past records or if such ethical or criminal investigations, charges, or convictions occur after this application is submitted or during my enrollment in the program. I understand that any information about me obtained in this manner will be treated confidentially and responsibly. I understand that any information about me obtained in this manner or my failure to divulge relevant information about me may be cause for a meeting of the Department of Education s Academic Standing, Program Compliance, and Professional Dispositions (ASPCPD) Committee to determine my continuance in this program. Signature Date RELEASE OF LIABILITY FROM EXCHANGE OF INFORMATION Because Christian Brothers University may be required to supply information concerning my program of study or my status in the Graduate Education Program to employing schools or school districts or to the State of Tennessee's (or another state's) certification or licensing bureau, I agree to hold Christian Brothers University harmless and to waive any liability on the part of Christian Brothers University for making a true, accurate, and factual representation of my status in the Graduate Education Program to these agencies. RELEASE OF RIGHTS TO VIEW RECOMMENDATION FORMS I hereby release my rights to review the contents of the recommendation forms that I have requested.

5 FINAL APPLICANT STATEMENT All information stated on and submitted with this application is true to the best of my knowledge. I also assume full responsibility to clarify, change, or add any information that may be deemed necessary to complete my requirements for admission to the Graduate Education Program. If I am admitted to the Program, I agree to update this information. I understand that, if I do not enroll after acceptance, my application and any requirements submitted with my application will be on file in the Department of Education at Christian Brothers University for only one year after the date of my signature below. TEACH FOR AMERICA AND MEMPHIS TEACHING FELLOWS ONLY EXPERIENTIAL LEARNING CREDIT FEE I understand that matriculation in the CBU M.Ed. Program for Teach for America/Memphis Teaching Fellows participants includes an obligation to pay a fee for 9 hours of experiential learning credit. The fee is $150 per credit hour ($1350 total). By signing this statement, I agree to pay this fee in the first semester of my enrollment. Signature of applicant Date VERIFICATION OF PARTICIPATION Instructions for applicants: Please have the designated official from your organization sign the statement below. My signature indicates that this applicant successfully completed a rigorous application process and is currently a participant in (check one) Teach for America or Memphis Teaching Fellows. Name of Official Signature of Official Date

6 NOTICE OF NON-DISCRIMINATION POLICY FOR STUDENTS Christian Brothers University admits students of any race, age, color, religion, sex, sexual orientation, national and ethnic origin to all the programs and activities of the University with the rights and privileges generally accorded to students. It does not discriminate on the basis of race, age, color, religion, sex, sexual orientation, national and ethnic origin or disability in administration of its educational policies, admissions policies, scholarship and loan programs, athletics and other University-administered programs. It is the policy of Christian Brothers University not to discriminate on the basis of sex in its educational programs, activities, or employment policies as required by Title IX of the 1972 Educational Amendments. DATA REQUIRED FOR UNIVERSITY RECORDS This information is not used in Admissions Decisions and completion of this portion is optional at this time. If you chose not to complete this information now but then are admitted to CBU and choose to enroll in courses, you must then complete this information for University records at the time of enrollment. 1. Marital Status: Single Married Divorced Separated Widowed 2. Gender: Male Female 3. Religious Preference: No Preference 4. What is your ethnicity? (choose one) Hispanic or Latino Not Hispanic or Latino 5. Select one or more races to indicate what you consider yourself to be: American Indian or Alaskan Native Black or African American Asian Native Hawaiian or Other Pacific Islander White 6. Have any members of your family attended Christian Brothers University at any time? If so, who? Name Relationship Name Relationship Name Relationship