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Azusa Pacific University (Azusa Pacific University)

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Statement of Experience
Please print or type.
Applicant’s name
Program name
Employer
Applicant’s signature Date
Please provide record of relevant paid and volunteer assignments. List most recent experience first. For each assignment, provide a
brief description of your responsibilities.
If the program for which you are applying requires verification of experience, your supervisor must sign this form.
Last Maiden (if applicable) First Middle Initial
Company Address
From: To:
DATES EMPLOYED
EMPLOYER OR SUPERVISOR
BRIEF DESCRIPTION OF RESPONSIBILITIES
LOCATION
TITLE OF SUPERVISOR
ASSIGNMENT
PHONE NUMBER
Hours/Week:
From: To:
DATES EMPLOYED
EMPLOYER OR SUPERVISOR
BRIEF DESCRIPTION OF RESPONSIBILITIES
LOCATION
TITLE OF SUPERVISOR
ASSIGNMENT
PHONE NUMBER
Hours/Week:
From: To:
DATES EMPLOYED
EMPLOYER OR SUPERVISOR
BRIEF DESCRIPTION OF RESPONSIBILITIES
LOCATION
TITLE OF SUPERVISOR
ASSIGNMENT
PHONE NUMBER
Hours/Week:
Continued...
A résumé may be submitted instead of the Statement of Experience, except for Physical Therapy applicants who must use this form.
APU ID number (if known):
Azusa Pacific University
GRADUATE AND PROFESSIONAL CENTER
Office of Graduate and Professional Admissions
From: To:
DATES EMPLOYED
EMPLOYER OR SUPERVISOR
BRIEF DESCRIPTION OF RESPONSIBILITIES
LOCATION
TITLE OF SUPERVISOR
ASSIGNMENT
PHONE NUMBER
Hours/Week:
Physical Therapy applicants
Please specify if situations include therapy experience for:
Transporter Modalities Observation Clerical Exercise Other (describe)
Please photocopy this form as necessary to obtain each supervisor’s signature needed.
Supervisor’s signature Date
Supervisor’s name (print) Position
Azusa Pacific University
STATEMENT OF EXPERIENCE
GRADUATE AND PROFESSIONAL CENTER • 568 E. FOOTHILL BLVD., PO BOX 7000, AZUSA, CA 91702–7000
(800) 825-5278 or (626) 815-4570 • FAX (626) 815-4545 • GPC@APU.EDU • APU.EDU/GPC
20130
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Azusa Pacific University (Azusa Pacific University)

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Completed 17 August 2020

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