Fillable Form 31705: Division of Education (Darton State College)

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Form 31705: Division of Education (Darton State College)

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File type: PDF

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Division of Education
Counselor Education Program Application for Admission
Document Name: Counselor-Education-Application-Form.Docx Page 1 of 3
Division of Education
Counselor Education Program Application for Admission
INTRODUCTION
Department of Counseling & Educational Leadership
Albany, GA
Billy C. Black Building
504 College Drive,
Office
Telephone: (229) 500-2149
31705
Room 244-I
DIRECTIONS: Please complete this application and return it to the Counselor Education program coordinator by
email (annie.lewis@asurams.edu) or postal mail.
PERSONAL DATA
NAME: __________________________________ ________________________________ _________ DATE: _____________________
Last First Int.
MAILING ADDRESS:
_________________________________________ _____________________________________________________ _____________
Number Street Apt Number
________________________________________________________ _______________________________ ____________________
City State Zip
TELEPHONE: _____________________________________________ _______________________________________________________
Preferred Telephone (day) Preferred Telephone (evening)
E
-MAIL: ________________________________________________________________________________________________________
D
ATE OF BIRTH: _______________________ GENDER: ________________________ RAM ID: ______________________________________
DEGREES AND LICENSE
CHOOSE ONE: □ NON- DEGREE ADVANCED □ COUNSELOR CERTIFICATION □ M. ED. DEGREE
P
LEASE INDICATE YOUR PREFERRED SEMESTER FOR BEGINNING THE COUNSELOR EDUCATION PROGRAM
Y
EAR: ________________________ □ SUMMER □ FALL
I
NDICATE YOUR PREFERRED COURSE PLANNING OPTION: □ 6 HOURS/SEMESTER □
9
HOURS
/
SEMESTER
D
O YOU HAVE A VALID COUNSELING LICENSE, EDUCATOR CERTIFICATION, OR OTHER PROFESSIONAL CREDENTIAL? □ YES □
N
O
COUNSELING LICENSE NUMBER:________________________________________________________________________________________
Albany State University Division of Education
Counselor Education Program Application for Admission
Document Name: Counselor-Education-Application-Form.Docx Page 2 of 3
IF YOU PLAN TO APPLY FOR LICENSURE, PLEASE INDICATE IN WHICH STATE: ___________________________________________________________
EDUCATION
_________________________________ ______________________________ _____________________ ______________________
Institution Graduation Date Degree Major
_________________________________ ______________________________ _____________________ ______________________
Institution Graduation Date Degree Major
_________________________________ ______________________________ _____________________ ______________________
Institution Graduation Date Degree Major
_________________________________ ______________________________ _____________________ ______________________
Institution Graduation Date Degree Major
EMPLOYMENT HISTORY
_________________________________ ______________________ ______________________ _____________________________
Employer Name Dates of Employment Job Title Brief description of duties
_________________________________ ______________________ ______________________ _____________________________
Employer Name Dates of Employment Job Title Brief description of duties
_________________________________ ______________________ ______________________ _____________________________
Employer Name Dates of Employment Job Title Brief description of duties
If you have additional work history or experiences that you think is relevant to your application for this program, please add it here _
What is your career goal and how will this degree help you attain that goal? _______________________________________________
Albany State University Division of Education
Counselor Education Program Application for Admission
Document Name: Counselor-Education-Application-Form.Docx Page 3 of 3
SCHOOL COUNSELING CONCENTRATION
If you are applying for the School Counseling concentration, have you passed the GACE or PRAXIS examination?
□ Yes □ No
If yes, which:
□ Medical Social Work □ Mental Retardation
□ Mental Health □ Substance Abuse
Are/will you apply for state certification?
□ Yes □ No
If yes, in which state(s)___________________________________________________________________________________________
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Form 31705: Division of Education (Darton State College)

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Completed 7 September 2020

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