Alabama State University is committed to providing equal opportunity for all qualified individuals and to policies and practices which will ensure that there is no discrimination against any person on the grounds of race, color, age, religion, sex, marital status, disability, national origin or veteran status. PERSONAL INFORMATION 1. Last Name, First Name, Middle/Maiden: 2. Prefix: Mr. Miss Mrs. Ms. 3. Current Street Address: 4. City: 5. State: - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 6. Birth Date: 7. Age: 8. Sex: Male Female 9. Student ID#: 10. Daytime Phone Number (including area code): 11. Evening Phone Number (including area code): 12. Person to notify in case of emergency: 13. Relationship to Emergency Contact: 14. Emergency Contact Phone Number (including area code): The following information is requested so that the University can comply with the reporting requirements of the U.S. Department of Education. 15. Are you a U.S. Citizen? Yes No 16. Please select: Non-Resident Alien Asian or Pacific Islander Black non-Hispanic Hispanic White non-Hispanic Other (Please specify below) Indian or Alaskan Native 17. If you answered "Other" to the previous question, please specify: ACADEMIC INFORMATION 1. Expected Graduation Date: 2. Major: 3. Career Goal: 4. Colleges and Universities Attended - Outside of Alabama State University (Include Name of Institution, Attended From/To, Degree and/or Major, and Overall GPA): VERIFIABLE SHADOWING/VOLUNTEER EXPERIENCE 1. Please list name of institution or organization, address, telephone and contact person/role. Include any within the last three years. APPLICATION INFORMATION 1. Please upload, in 500 words or less, a typed essay on "Why I want to pursue the MCH Undergraduate Certificate." Upload Upload requirementsOne file only.100 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. 2. Are you currently on scholarship? Yes No 3. How did you hear about the certificate program? 4. Have you requested official copies of transcripts be sent to the Maternal and Child Health Undergraduate Certificate Program (COHS)? Yes No By submitting this application, you certify that all information is complete and accurate. In the event that you are admitted to Alabama State University, you agree to abide by the rules and regulations of the institution. Submit
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