Full Name:	First:   Middle:   Last:
Permanent Mailing Address:	City:   State:   Zip:
Until When:
Preferred Mailing Address (if different):	City:   State:   Zip:
Until When:
Permanent Phone:
Local Phone:
Cell Phone:
E-mail:

Are you a U.S. Citizen?:	Yes    No    |    Social Security Number:
If no, do you have or are you eligible for a VISA?:	Yes    No
Please select one:	I will complete a bachelors degree this year.   Major: I have a bachelors degree.   Major: I have a two-year degree.   Major: I do not have a college degree.
Are you currently a University of Mary student:	Yes    No
If so, how many semesters have you completed:
Please indicate your intended program of study:	Master of Science in Occupational Therapy Bachelor of Science in related field to M.S. in Occupational Therapy Occupational Therapy Assistant to M.S. in Occupational Therapy
This is my:	First application   Reapplication - Year previously applied:

Please complete the following section for all post-secondary educational institutions you are attending or have attended. Begin with the most recent school.
Institution	State	From (Month/Year) - To (Month/Year)	Semesters	Degree Earned
Additional information: Please clarify/expand on your plan to complete any admission criteria not met at the time of your application:

Please provide information regarding your latest work history:
Employer	Dates From (Month/Year) - To (Month/Year)	Job Duties & Responsibilities

You must download submit the Recommendation and Appraisal Form and Volunteer Work and Community Service Verification Form. Recommendation and Appraisal Form Volunteer Work and Community Service Verification Form This information is necessary to fully consider your application to the program. Print three (3) copies of the Recommendation and Appraisal Form and follow the directions on the form. References must be sumitted in original, sealed envelopes, with the signature of the referring individual across the seal. References submitted without required signature across the seal will not be accepted. References and Volunteer Work Verification Form should be mailed to: OT Admission Committee Department of Occupational Therapy Univeristy of Mary 7500 University Drive Bismarck, ND 58504

The University of Mary, like other public and private colleges and universities, has a policy regarding the admission of persons with a criminal history. Having a criminal record will not automatically prevent an applicant from being admitted to a course of study at the University of Mary. Applicants are required to answer all of the following questions. Applicants who provide affirmative responses to any question will be asked to provide additional information which will be reviewed by the Academic Standards and Admissions Committee. Falsification or omission of information may result in a denial of admission, rescission of admission, dismissal, or other appropriated action.
Yes    No	1. Have you ever pled guilty (or no contest) to or been convicted of any felony?
Yes    No	2. Within the past 10 years, have you pled guilty (or no contest) or received a deferred prosecution or otherwise been convicted of a misdemeanor crime involving violence or the threat of violence in any court? ("Crime of violence" means an offense in which physical force was used, attempted or threatened against the person or property of another or by the nature of the offense it 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	3. Are you currently under investigation for any crime of the type described in questions one or two?
Yes    No	4. Are you currently under a violence protection order?
Yes    No	5. Are you currently on probation, under court supervision, or participating in any other pre-conviction program in any court of law?
Yes    No	6. Are you currently required to register as a sex offender in any state?
Yes    No	7. Have you ever been dismissed and/or suspended from a college or university because of conduct?
If yes to any of the above, please explain:
I verify that the information I have provided to the University of Mary Occupational Therapy Admissions Committee is accurate. I understand submitting falsified information will result in denial of admission or immediate dismissal from the program.