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Master of Public Health ProgramApplication for Admission

1 NAME:              Last First M.I.

2 Will you be 100% Online Yes NoFull time 9 or more hours Yes No

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down list.

Degree sought ->

and/or Certificate ->

3             -> ->UIN (if any) Maiden name (if any) Term of entry Year of entry

4                     Street City State Zip

5                         Home Phone Work Phone Cell E-Mail (you check often)

6List those individuals you have asked to provide a reference for you (acceptable from the referee’s email account directly to mph@uis.edu).Include the form at… http://www.uis.edu/publichealth/wp-content/uploads/sites/62/2013/03/MPH-Reference-Form.docx

Name Phone (area code and #)     

Email     A                  

B                  

C                  7 Submit a 300 word ACADEMIC ESSAY answering these three questions.

1) What are the most urgent public health problems facing your community today?2) How will a master’s degree in public health help prepare you to address these problems?3) Which area of public health specialization appeals most to you?

Please submit this Application Form, Academic Essay (see instructions), and a resumé to:University of Illinois at SpringfieldDepartment of Public HealthOne University Plaza, MS PAC 309Springfield, IL 62703-5407

217-206-6720Fax 217-206-7807mph@uis.edu

NOTE:You must also submit the university application and official transcripts to UIS Admissions Office8 Please check here if you have or intend to apply for a graduate assistantship.

Please check here if you have or intend to apply for a Graduate Public Service Internship. Please check here if you seek the Professional Option track Professional Track Option

9 How did you hear about the UIS Master of Public Health program (check all that apply): Career fair Illinois Environmental Health Association

Newsletter

Illinois Virtual Campus Illinois Public Health Association Newsletter

Internet Search Journal of Environmental Health

On-campus Advertising University of Illinois Online (UIOL)

Personal recommendation Other (please specify below)

The University of Illinois at Springfield haa an active equal opportunity admissions program. Rev: 1 January 2013

The University of Illinois at Springfield haa an active equal opportunity admissions program. Rev: 1 January 2013