Phillips Graduate Institute (CA) Application

Application Instructions

* Complete every question. Required fields are marked with *.

* A  next to the question provides additional information.

* A  on the sidebar indicates that all required information has been completed for that page.

* Use the tab key or mouse to move through the fields.

* Current students may log in to Tigernet; some questions will be populated automatically.

* The form will automatically save when you move on to another tab by pressing the Next button.

* Once you submit your application, you will no longer have access to it.

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Phillips Graduate Institute (CA) Application

*Please enter your name as it appears on your passport.

First Name:

Last Name: (Family Name)

Middle Name:

Prefix:

Preferred Name:

Previous Name:

Mobile Phone Number:

Home Phone Number:

Email Address:

Confirm Email Address:

Phillips Graduate Institute (CA) Application

Social Security Number:

Gender:

Date of Birth:

Marital Status:

Ethnicity:

Race:

African American (Black) - A person having origins in any of the black racial groups of Africa. 

American Indian or Alaskan Native - A person having origins in any of the original peoples of North and South America (including Central America) who maintains cultural identification through tribal affiliation or community attachment.

Asian - A person having origins in any of the original peoples of the Far East, SoutheastAsia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Native Hawaiian or Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Phillips Graduate Institute (CA) Application

Citizenship Status:

Resident Registration Number:

Country of Citizenship:

Country of Birth:

City of Birth:

Do you have a current U.S. VISA?

VISA Type:

VISA Expiration Date:

Phillips Graduate Institute (CA) Application

Country:

State: (Province, Prefecture, District, Region)

City:

Address:

Address Line 2 (Apt/Suite#):

ZIP Code:

Phillips Graduate Institute (CA) Application

What year do you wish to enroll?

What term do you wish to enroll?

What program are you seeking?

I prefer to have my full cohort day on:

Phillips Graduate Institute (CA) Application

Have you ever applied to Phillips or Campbellsville before? When?

Have you ever attended Phillips or Campbellsville before? When?

Have you ever been dismissed from a college or university? (If yes, you will be required to submit an explanation.)

Will you be requesting transfer credits (units must be at the graduate level)?

*If yes, please complete the Transfer Credit Request Form and submit it along with your supporting documents:

List any honors, awards, and scholarships you have received, any positions you have held in the community or professional life, and any publications in your name:

*List each with their beginning date

Previous Educational Institutions Attended:

Enter the information needed and press the Add button, the information will show up in the table below. If you need to add another entry you may press the Add button again. To update any entry you can do so by clicking on the Update button and once you are finished you can save it by clicking on the Add button. You can also view the entry details if available by pressing the Details button.

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State of Institution:

Name of Institution:

Degree:

Did you graduate from this Institution?

Date Degree Earned or Anticipated:

Start Date:

End Date:

Phillips Graduate Institute (CA) Application

How did you first learn about the Phillips Graduate Institute's MMFT program?

(Please be specific)

If you were referred by a current student, faculty or staff member, or a Phillips graduate, please add their name and contact information below:

Phillips Connection(s)

Enter the information needed and press the Add button, the information will show up in the table below. If you need to add another entry you may press the Add button again. To update any entry you can do so by clicking on the Update button and once you are finished you can save it by clicking on the Add button. You can also view the entry details if available by pressing the Details button.

First Name:

Last Name:

Phone Number:

Email Address:

Employment Information

Status of Employment:

Employment Industry:

Phillips Graduate Institute (CA) Application

Have you ever been convicted of a felony?

Please explain:

Are you interested in Financial Aid?

Do you qualify for Veterans Benefits?

Verify your application is complete

Each tab on the left side of the screen should have a  next to it to indicate you have supplied all the required information. You will not be able to submit your application unless EVERY tab has a . You can go back to the page now and complete the required information, or log back in later and retrieve the application using the email and password you created when you started.

Certify your statements

I hereby certify that the above statements are true and correct to the best of my knowledge. I hereby submit this application for admission to Campbellsville University subject to the policies and procedures of the university.

1.) I understand that if admitted to Campbellsville University, I must comply with all rules, regulations, and policies of Campbellsville University. I understand that admission to and matriculation in the program in no manner guarantees successful completion of the program and the awarding of a degree. I hereby affirm that the information supplied by me on this application form is true and correct to the best of my knowledge and understand that omissions or falsification may result in withdrawal of acceptance.

2.) I understand the training for which I hereby make application will not in itself qualify me for the California license as a Marriage and Family Therapist (MFT). Programs at Campbellsville satisfy only the minimum education requirements for the aforementioned licenses, registrations and/or credentials.

3.) It is further recognized by the undersigned that initial acceptance into the program does not obligate Campbellsville University, nor any of its representatives, to maintain any student in the program if said student is found to be unfit for the program by any reason of personality, academic or attitudinal characteristics, or because of unmet financial obligations.

4.) Since this is a program, which involves the development of professional potential in interpersonal relationships, I understand that I will be required to attend an interview prior to enrollment in the program.

5.) Any questions or problems concerning this institution which have not been satisfactorily answered or resolved by the institution should be directed to the Superintendent of Public Instruction, State Department of Education, Sacramento, California 95814.

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