For Office Use Only

App. Fee:

MOP:

Cash:                         Ck #:

Card #:

Expiration Date:

Security code:

CK MO CC:

ADMISSION APPLICATION

Date:

First Name:

E-Mail:

Middle Initial

Last Name

International Phone #:

International Fax #:

U.S. Phone Number:

U.S. Fax Number:

List any other name(s) which may appear on transcripts or test score reports which may differ from the name listed above

First Name

First Name

Current Age

Middle Initial

Middle Initial

Last Name

Last Name

Date of Birth:

 
Permanent Address:

Street Address 1:

Street Address 2:

City:

State:

Zip Code:

Country:

Residency:

Street Address 1:

Street Address 2:

City:

State:

Zip Code:

Country:

 
Enrollment:

When do you plan to begin your enrollment?  Check all that Apply.

Fall Semester

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Spring Semester

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Summer Intensive

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Winter Intensive

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Education History:

Please furnish to the best of your ability your undergraduate and graduate grade point averages (GPA) providing the numerical equivalent of  the following scale:  A=4.0, A-=3.67-3.9, B+= 3.33- 3.66, B=3.0, B- =2.67 - 2.9, C+ = 2.1 - 2.33, C= 2.0...F=0.0. 

Name of Institution 1

Status: ie: undergrad

Expected Graduation Date:

Overall Cumulative Average:

Number of Years Attended:

Degree:

Major Field of Study Degree:

Name of Institution 2

Status: ie: undergrad

Expected Graduation Date:

Overall Cumulative Average:

Number of Years Attended:

Degree:

Major Field of Study Degree:

Name of Institution 3

Status: ie: undergrad

Expected Graduation Date:

Overall Cumulative Average:

Number of Years Attended:

Degree:

Major Field of Study Degree:

References:

Name three or more persons acquainted with your academic and/or professional experience.  Please include at  three Recommendation Letters.  Please have each reference listed.  Recommendation letters can be e-mailed to info@pocsinstitute.org.  Please have them indicate your name as the student in the letter.

Title/Postion

Reference #1:

First Name:

E-Mail:

International Phone #:

International Fax #:

Last Name

Affiliation with Applicant

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U.S. Phone Number:

U.S. Fax Number:

Reference #2:

Reference #3:

Reference #4:

 
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175 St. Bridget's Drive

Rochester, New York

14604