Application for Postgraduate Admission

2017-2018 Academic Year

All applicants must submit a completed application.

The Admissions Committee will not review incomplete applications.

Office of Postgraduate Admissions Office of International Admissions

218 Libermann Hall 600 Forbes Avenue 600 Forbes Avenue
Pittsburgh, PA 15282 Pittsburgh, PA 15282-1201 USA
 APPLICATION FOR POSTGRADUATE ADMISSION

Be sure to type or print clearly in ink. Incomplete applications will not be reviewed.
Check One: ❏ U.S. Citizen ❏ Permanent Resident/Greencard #:_____________ ❏ International Applicant/Country of Citizenship*:__________

A. PERSONAL INFORMATION
Legal Name __________________________________________________________________________________________ ❏ Male ❏ Female
Last First Middle

Home Address__________________________________________ City _______________________ State/Province _________________________

Zip/Postal Code _____________ County ________________Country____________________ Birth Country__________________________________

Preferred Contact Number (_____)_______________ Date of Birth(mm/dd/yyyy)________________Birth City_______________________________

E-mail__________________________________ U.S. Social Security Number _________-______-_________ (If available for international students.)

Are you related to an alumnus of Duquesne University? ____ Yes ____ No If yes, please complete the following:
Relationship __________________________ Name _______________________________ Degrees/Date ________________________
Relationship __________________________ Name _______________________________ Degrees/Date ________________________

What is your ethnicity?

❏ Hispanic or Latino ❏ Not Hispanic or Latino
Select one or more races to indicate what you consider yourself to be.
❏ American Indian or Alaska Native ❏ Asian ❏ Black or African American
❏ Native Hawaiian or other Pacific Islander ❏ White
Religious Denomination or Rite ____________________________________________

B. ENROLLMENT STATUS
Anticipated Entry Term ___ Fall (August) ___ Spring (January) ___Summer (May) Year: 20________
Do you plan to live on campus? ❏ Yes ❏ No

ACADEMIC PLANS

Academic Programs (Please choose one.)

Biomedical Engineering M.S.Ed.

_M.S. Biomedical Engineering _Child Psychology
_Clinical Mental Health Counseling
_Early Level (PreK- 4)
Business
_Educational Studies - Educational Studies, Program Evaluation,
Certificate
_Classroom Assessment
_Master's Certificate in Supply Chain Management
_English as a Second Language and Certificate Programs
_Instructional Technology (online)
MBA Programs
_Marriage, Couple and Family Counseling
Professional MBA (evening and online, part-time/full-time)
_Reading and Language Arts
MBA Sustainable Business Practices (daytime, full-time)
_School Administration K-12
_School Counseling
Specialized Master's
_School Counseling for Certified Teachers
_MS in Accountancy
_School Supervision
_MS in Information Systems
_Secondary Education - English
_ManagementMS in Management (online)
_Secondary Education - Latin
_MS in Sports Business (online)
_Secondary Education - Mathematics
_MS in Supply Chain Management
_Secondary Education - Sciences
_Secondary Education - Social Studies
Education _Special Education - Cognitive, Behavior, Physical/Health
Certification/Licensure Only Programs _Disabilities (PreK-8, 7-12)
_Board Certified Behavior Analyst (BCBA) _Special Education - Community and Special Education Support
_Counselor Licensure
_School Counseling Certification Ed.D.
_School Supervision _Instructional Technology (online)
_TESOL Certificate _Educational Leadership

Endorsements Ph.D.
_Autism Spectrum Disorders Endorsement _Counselor EducationSchool
_Online Teaching Endorsement (online) _PsychologySpecial Education

Post-Master's Programs Psy.D.

_Counselor Licensure _School Psychology
_School Counseling Certification

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 ACADEMIC PLANS

Academic Programs (Please choose one.)

Health Sciences Music

_M.H.M.S. Certificate
_Health Management Systems _Music Education
_Music Therapy
M.S.
_Speech-Language Pathology M.M.
_Music Performance
M.P.A. _Sacred Music
_Physician Assistant
Artist Diploma
D.P.T. _Music Performance
_Physical TherapyO.T.D. _Chamber Music
_Occupational Therapy
_Post-Professional Doctorate in Occupational Therapy Natural and Environmental Sciences
Certificate
Ph.D. _Environmental Management
_Rehabilitation Science _Environmental Science

Law M.S.
_L.L.M. _Biotechnology
_Laws and Letters (Foreign Lawyer) _Environmental Science and Management

J.D. Ph.D.
_Law - Juris Doctor _Biological Sciences
_Law/Master of Business Administration _Chemistry and Biochemistry
_Law/Master of Health Care Ethics
_Law/Master of Science in Environmental Science & Nursing
_Management Law/Master of Divinity Post-Master's Certificate
_Law/Master of Philosophy _Family (Individual Across the Lifespan) Nurse Practitioner (online)
_Forensic Nursing (online)
Liberal Arts _Nursing Education and Faculty Role (online)
Certificate
_Healthcare Ethics M.S.N.
_Interpretive and Qualitative _Family (Individual Across the Lifespan) Nurse Practitioner (online)
_Research Media Arts _Forensic Nursing (online)
_Pastoral Ministry _Nursing Education and Faculty Role (online)
_Women's and Gender Studies
D.N.P
M.A. _Doctor of Nursing Practice (online)
_Communication & Rhetorical Studies
Ph.D.
• Corporate Communication (Specializations: Crisis and Risk
_Nursing (online)
Communication, Management Nonprofit Communication or Integrated
_Nursing Ethics (online)
Marketing Communication)
• Communication (Emphasis Areas: Communcation Studies or Rhetoric
and Philosophy Pharmaceutical Sciences
• Rhetoric & Philosophy of Communication PharmD
• Dual Degree M.A. Programs _Weekend Pharmacy (Doctor of Pharmacy)

_English M.S./Ph.D.
_Healthcare Ethics _History _Medicinal Chemistry
_Pastoral Ministry _Philosophy _Pharmaceutics
_Public History _Pharmacology
_Religious
_EducationTheology M.S.
_Pharmacy Administration
M.S.
_Computational Mathematics Leadership (online) Post-Baccalaureate Pre-Medical
Multimedia Arts & Technology Certificate
• Digital Media _Post-Baccalaureate Pre-Medical Program (PB-PMHPP)
• Media Management
• Web Design and Development Certificate/Dual Program
_PB-PMHPP/Master's of Biotechnology
Ph.D. _PB-PMHPP/Master's of Health Management
_Clinical Psychology _SystemsPB-PMHPP/Master's of Healthcare Ethics
_English
_Philosophy
_Rhetoric
_Systematic Theology

Ph.D./DHCE
_Healthcare Ethics

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C. EDUCATIONAL BACKGROUND
Previous College/University Information

School Name ____________________________________ CEEB Code ______________ School Phone Number (______) ___________________

School Address ___________________________________________________________________________________________________________

City _____________________________ State/Province _______________ Zip/Postal Code ___________ Country___________________________

Counselor’s Name ____________________________________Counselor’s E-mail Address______________________________________________

Attended from (mm/yyyy) __________Attended to (mm/yyyy)___________Expected/Conferred Degree Date (mm/dd/yyyy)____________

Degree Type (Specify Undergraduate, Graduate, Doctorate, Other) ______________________

Program of Study/Major or Degree/Expected/Earned ______________________

Have you taken the IELTS or TOEFL Exam? __Yes __No

D. PERSONAL INFORMATION
1. Have you ever been convicted, pled guilty or no contest (nolo contendere) to a crime other than a summary traffic offense?
____Yes ____ No (If yes, attach a separate sheet and describe in full detail.)

2. Are there any criminal charges presently pending against you other than a summary traffic offense? ____ Yes ____ No
(If yes, attach a separate sheet and describe in full detail.)

3. Are you eligible to participate in any tuition assistance programs such as SAGE, TAP, Tuition Exchange, etc.? ____ Yes ____ No
If yes, please list program:____________________________________________ If SAGE, what is the amount of your tuition reward?___________

4. List all dates you have taken or plan to take the SAT/ACT (Mo./Yr.): ___________ ___________ ___________ ___________ ___________

5. Are you a seminarian? ____ Yes ____ No

6. Are you a Duquesne employee or the son or daughter of a full-time Duquesne employee? ____ Yes ____ No
If yes, list employee’s name and department: _________________________________________________________________________________

7. Are you a sister, brother, niece or nephew of a Spiritan Father or Brother? ____ Yes ____ No
If yes, list relative’s name and relationship: ___________________________________________________________________________________

8. Are you a veteran? ____ Yes ____ No

If yes, have you served at least 90 days on active duty after September 10, 2001? ____ Yes ____ No

9. Are you the spouse of a veteran? ____ Yes ____ No

If no, are you the dependent (daughter or son) of a veteran? ____ Yes ____ No

E. FAMILY INFORMATION

Father/Guardian/Spouse ____________________________________ Mother/Guardian/Spouse_____________________________________

Address_____________________________City__________________ Address_____________________________ City___________________

State/Province _____________ Zip/Postal Code _________________ State/Province ______________Zip/Postal Code__________________

County _______________________ Country ____________________ County _______________________ Country _____________________

Home Phone (____) ___________Work Phone (____)_____________ Home Phone (____) ___________Work Phone (____)______________

E-mail Address ____________________________________________ E-mail Address _____________________________________________

Occupation _______________________________________________ Occupation ________________________________________________

List any degrees___________________________________________ List any degrees ___________________________________________

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 F. SIGNATURE
ALL APPLICANTS: Sign and date this application below and submit a non-refundable application fee of $50 (US) payable to Duquesne University.
I understand that my continuance at the University, the receipt of academic credits, graduation, and the conferring of any degree or the granting of
any certificate are strictly subject to the disciplinary authority of the University, which is vested in the President, and subject to his reserved powers,
in the dean of each faculty. Your signature below indicates that you have read this application carefully and that the information you have provided
is correct and complete.

Signature _________________________________________________________ Date _____________________________________________

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 OFFICE OF INTERNATIONAL PROGRAMS
For Use By International Applicants Only
601 Duquesne Union • Pittsburgh, PA 15282 U.S.A.

AFFIDAVIT OF FINANCIAL SUPPORT FORM

[email protected]
Fax 412.396.5178

INSTRUCTIONS: Please PRINT or TYPE. This form has two initial parts — one for privately supported students and one for agency-supported
students. Privately supported students receive financial support from their own resources, their parents, or a relative/friend. Agency-supported
students receive support from a government or other agency.You need to complete only one of the first two parts (private or agency), unless
you will receive support from both of these sources. All applicants, including scholarship candidates, must complete part 3.

This form must be accompanied by evidence of available finances in the form of original notarized or certified official BANK STATEMENTS,
EMPLOYER’S GUARANTEE/STATEMENTS, or AGENCY FINANCIAL GUARANTEE. No uncertified photocopies can be accepted. Certified/
notarized documents are those that have been stamped with a seal of authentication by an authorized official.

Be sure to sign this form after completing Part 1 OR Part 2 AND Part 3. (No immigration documents can be issued until all financial resource
certifications have been received by Duquesne University.) Part 3 must be completed and notarized to make this document official.

Name of Applicant
Last (Family Name) First (Given Name) Middle

Country of Citizenship Date of Birth
Month/Day/Year

PART 1 — PRIVATELY SUPPORTED STUDENTS

As the financial sponsor of the applicant whose name appears above, I attest to my ability to furnish financial support for expenses of
the above applicant’s study at Duquesne University and am providing evidence of available funds for the academic year specified for
the program indicated in this application.

Name of Sponsor

Relationship to Sponsored Student

Signature of Sponsor

Date Signature and Seal of Notary

PART 2 — AGENCY-SUPPORTED STUDENTS

As the financial sponsor of the applicant whose name appears above, our organization will financially support the applicant’s study at
Duquesne University.

Name of Agency

Student’s Agency Identification Number (if known) Date

Name and Title of Agency Authorizing Official

PART 3 — FINANCIAL RESOURCES AVAILABLE: SUMMARY STATEMENT

NOTE: Institutional compliance with U.S. law and immigration regulations requires that all international applicants provide
evidence of sufficient financial resources to support their education. The total funds available to you from all sources (whether
single or combined) must meet the total of estimated academic year costs for your degree program at Duquesne University.
Duquesne will not issue immigration documents without this documentation as defined above. The amounts below must match
the amounts indicated on the bank statements/financial guarantees provided.

1) Personal Funds Available...........................$ Bank Certification enclosed

2) Agency Funds Available.............................$ Financial Guarantee enclosed

3) Total (1 and/or 2).........................................$

I certify that the information provided in this Affidavit of Financial Support Form is correct and complete. All privately supported
students must have this form notarized with appropriate signature and seal before submission.

Signature of Applicant Date

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 OPTIONAL RECOMMENDATION FORM

Please have this form completed by an academic source at your school and return to Office of Admissions, Duquesne University,
600 Forbes Ave., Pittsburgh PA, 15282, fax to 412.396.5644, or e-mail to [email protected].

Note: Health Sciences, Pharmacy, Forensic Science, Natural and Environmental Sciences and Nursing applicants should request a
recommendation from either a science or math teacher.

Applicant’s Name ___________________________________________________________________________________________________

High School Name, City and State _____________________________________________________________________________________

Please check one column in each line to critique the applicant’s character and abilities.

Excellent Good Average Below Average No Basis

Character and Personality
Integrity and Values
Leadership
Emotional Maturity
Extracurricular Involvement
Contributions to the School/Community

Intellectual Ability and Achievement

Intellect
Creativity
Critical Thinking
Motivation/Initiative
Communication Skills

Overall Evaluation and Comments:

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

How long have you known the applicant? _______________________________________________________________________________

What is your relationship to the applicant? _______________________________________________________________________________

My judgment on this individual regarding admission to Duquesne University is to: (check one)

❏ Recommend ❏ Do not recommend ❏ Recommend with hesitation

Your Name: ______________________________________________ Occupation/Title:___________________________________________

Phone: _________________________________________________   E-mail:___________________________________________________    

Address: __________________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Signature________________________________________________ Date____________________________________________________

Do you authorize the Disclosure/Release of this recommendation to the applicant? ❏ Yes ❏ No

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 Notice of Nondiscrimination Policy
It is the policy of Duquesne University to admit those applicants who are best
qualified to profit from the opportunities it offers for intellectual, spiritual and social
growth. It does not discriminate on the basis of religious preference, sex, race, color,
national or ethnic origin, non-performance-related handicap or veteran’s status in the
administration of its educational policies, admissions policies, scholarship and loan
programs, and athletics or other University-sponsored programs.

Security Statistics, Policies and Procedures

Pursuant to the requirements of the PA College and University Security Information
Act and the Clery Campus Crime Statistics Act, the annual Campus Security Report
can be found on the University website at www.duq.edu or a copy can be requested
from the University Public Safety Department at 412.396.6002. The Report contains
three years of on/off campus crime statistics, the University’s policy statement, a
description of relevant campus programs and the procedures for reporting crimes.
Daily crime logs are available for review in the Department of Public Safety by calling
412.396.6007 from 8:30 a.m. to 4:30 p.m., Monday through Friday.
350972 10/17

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