Graduate Certificate Program in Disabilities Application

Please complete this application fully and accurately, which will insure that it may be processed without delay. If you are unable to respond to any item, please indicate that it is not applicable by marking it “NA”. If you are not a graduate student at Wayne State University, you will need to contact the Wayne State University Graduate School (313.577.2170) for admissions information. If you have questions or need clarification regarding this application, please contact Elizabeth Janks, Graduate Certificate Program Coordinator, via the contact information provided in this application.

Fields with asterisks (*) are required.

First name *

Last name *

Email *

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Work/Cell Phone *

Graduate-Level Educational Background

Note: Please have college transcripts sent directly to Elizabeth Janks, Graduate Certificate
Program Coordinator, Developmental Disabilities Institute, via the contact information provided
in this application.

1. Current College/University *

Department/Division *

Degree being pursued *

Major/Cognate

Date of Entry into Program *

Anticipated Date of Program Completion *

Major Academic Advisor *

Phone *

2. Previous College/University

Department/Division

Degree Awarded

Major

Minor/Cognate

Date of Entry into Program

Date of Program Completion

Major Academic Advisor

Phone

Undergraduate Educational Background

1. College/University *

Department/Division *

Minor/Cognate

Date of Program Completion *

Major Academic Advisor *

Phone *

Work Experience

1. Agency/Organization Name *

Supervisor Name and Title *

Agency Address *

Agency City *

Agency State *

Agency State/Zip Code *

Agency Phone *

Agency Website/E-mail *

Dates Employed *

Position *

Responsibilities *

2. Agency/Organization Name *

Supervisor Name and Title *

Agency Address *

Agency City *

Agency State/Zip Code *

Agency Phone *

Agency Website/Email *

Dates Employed *

Responsibilities *

3. Agency/ Organization Name *

Supervisor Name and Title *

Agency Address *

Agency City *

Agency State/Zip Code *

Agency Phone *

Agency Website/E-mail *

Dates Employed *

Position *

Responsibilities *

4. Agency/Organization *

Supervisor Name and Title *

Agency Address *

Agency City *

Agency City/State *

Agency Phone *

Agency Website/E-mail *

Dates Employed *

Position *

Responsibilities *

Letters of Support/ References

Please provide names and contact information for the three people whom you will be asking to
write letters of support for your application. Please contact these individuals and ask them to
send letters of support/reference directly to Elizabeth Janks, Graduate Certificate Program
Coordinator, Developmental Disabilities Institute, via the contact information provided in this
application. ALL LETTERS OF RECOMMENDATIONS MUST BE MAILED DIRECTLY TO ELIZBETH JANKS, EMAIL SUBMISSIONS WILL NOT BE ACCEPTED.

1. Name *

Agency/Organization Name *

Address *

Phone

E-Mail Address

Length of Acquaintance

Please provide a statement of what you hope to accomplish by participating in the
Developmental Disabilities Institute’s Graduate Certificate in Disabilities Program. Indicate
both interests you wish to pursue while in the Program and contributions you hope to make to the
field after Program completion.

Program Goal Statement *

Current Curriculum Vitae/Resume *

Undergraduate Unofficial Transcript

Checking the box below indicates that the information in this application is complete, accurate and up-to-date to the best of my knowledge. It is also my explicit consent for contact with employers, advisors and references to confirm the information contained in this application. *

I agree