SIU College of Education-Application for Professional Experiences

Application for Professional Education Experiences

Room 135, Wham Education Building, Mailcode 4612

Southern Illinois University at Carbondale

Carbondale, Illinois 62901-4612

(Submit in Quadruplicate)

DIRECTIONS FOR COMPLETING THE ELECTRONIC FORMS:

Most of the information needed below will be in the form of keyboard input (e.g., typing name, address, etc.) There are some areas where a checkmark is required in the appropriate box. For those choices, just click the mouse button on the desired box and a checkmark will appear. To uncheck a box, just click the mouse button a second time. There may be boxes that have predefined choices (e.g., expected graduation date). Click on the arrow on the right-hand side of that box and items that can be chosen will appear in a drop-down list--just click the desired choice.

Once you have completed all the information for the form, scroll to the bottom of the page. Two buttons are located there: one for generating a printable document and one for resetting the document. If you decide you want to start over, click on reset and all the information completed will be removed. Before the form can be printed, a printable version must be generated. Click on the Generate Printable Document button. The completed form will appear on the screen in a format that can be printed.

If you notice a mistake on the generated form, just click the Back button on the browser to return to the input form. Make any necessary changes and regenerate the printable document.

So that you may receive the best Professional Semester assignment possible, it is necessary that you complete each blank fully unless it does not apply to you as a future clinical teacher.

Name

Male Female

Carbondale Address Phone

Home Address

City State Zip Phone

E-Mail Address

College of Enrollment

At this time I am requesting a fall, spring, (4-digit year), Professional Semester assignment.

I expect to graduate (Mo.) (4-digit year) Undergraduate Graduate

I graduated from High School,

(City), (State) in (Year).

My major is

area of specialization

My minors are

and

Total semester hours to date in major field minor fields and

I will have completed the following courses in major and minor fields prior to the beginning of the Professional Semester. (This information need not be given from an official transcript. Obtain titles and numbers of courses from the Undergraduate Catalog.)

Major:

Course No.	Title of Course

Minor:

Course No.	Title of Course

Education Courses

Course No.	Title of Course

At the end of the semester prior to the Professional Semester, I will have semester hours from SIU at Carbondale and

semester hours from

(Colleges or Universities other than SIU at Carbondale).