Valley City State University
Valley City, North Dakota
SEGS 1-13
Application
APPLICATION FOR ADMISSION TO TEACHER EDUCATION
Applicants must meet the criteria for Admission to Teacher Education to be admitted. Criteria are listed on page 7 of the Teacher Education
Handbook.
Date:
Name:
Last
First
Permanent Address:
Student ID:
Middle or Maiden
Street
City
Phone Number:
Enrolled at VCSU:
Major(s):
State
Zip Code
Date of Birth:
Semester
Year
Minor(s) or Endorsement(s):
Previous College(s) Attended:
Required Information:
All students making application must answer the following questions. An affirmative response to any of these questions will not automatically
prevent admission, but you will be asked to provide additional information. The information will be reviewed by a campus officer or committee
charged with that responsibility. Falsification or omission of information may result in denial of admission, rescission of admission, dismissal
or other appropriate sanction.
1.
2.
3.
4.
5.
6.
Are you on academic probation?
Yes
No
Have you ever been on academic probation?
Yes
No
Have you ever pled guilty (or no contest) to or been convicted of any felony?
Yes
No
Within the past 10 years, have you pled guilty (or no contest) to or otherwise been convicted of a misdemeanor crime involving violence or
threat of violence in any court? (“Crime of violence” means an offense that involves substantial risk that physical force may be used
against a person or property of another. Examples of crimes of violence include, but are not limited to, abuse, arson, assault (including
sexual assault or domestic violence), battery, breaking and entering, burglary, criminal mischief, or vandalism, harassment, homicide,
menacing, reckless endangerment, stalking, terrorizing and unlawful restraint or imprisonment.
Yes
No
Are you currently required to register as a sex offender in any state?
Yes
No
Have you been dismissed from a college or university for disciplinary reasons within the last 5 years? (“Dismissed for disciplinary
reasons” means a permanent separation from an institution due to conduct or behavior. “Suspended for disciplinary reasons” means a
sanction imposed for disciplinary reasons that results in a student leaving school for a fixed period of time but not permanently.)
Yes
No
A criminal background check will be completed prior to the completion of the program.
Two of the four professors listed below will be contacted by the Education Office to provide a recommendation on your potential as a teacher.
These professors should be from the School of Education or your content area. Transfer Students: If you are a transfer student in an
articulation program you may list at least one VCSU professor and professors from your home campus.
Professor’s Name
Course Number/Name
Semester/Year
For Advisor’s Use Only:
Please take this form to your advisor and complete the program planning he/she directs.
I have planned an appropriate program for this applicant. At this point my best judgment is to:
Recommend the student for admission to Teacher Education
Not recommend the student for admission to Teacher Education
Date
Advisor’s signature
This form should be submitted to the Education Office, Valley City State University, 101 College Street SW, Valley City, ND 58072 or faxed to (701) 845-7190.
Valley City State University
Valley City, North Dakota
SEGS 1-13
Application
For Education Office Use Only:
Overall GPA
Signature
Registrar’s Office
Course
Date
Grade
Verified
Action
ENGL 110
[ ] Admitted to Teacher Education
ENGL 120
[ ] Conditional Admission
EDUC 250
[ ] Admission Denied
Date
Signature
Dean of Education
This form should be submitted to the Education Office, Valley City State University, 101 College Street SW, Valley City, ND 58072 or faxed to (701) 845-7190.