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Please enter your full legal name including any maiden names.
      Last First Middle Maiden

Program of Study



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How did you learn about our program?

Have you ever been enrolled in any other social work program?

Did you graduate? (If you have ever left a social work program without graduating, check no.)

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Education: Please list all colleges and universities previously attended and specify any degrees received or to be received.
     School Name School Location Major Dates Attended Type of Degree Received Date of Degree

Students are required to submit official transcripts from all colleges and universities attended to the University of Memphis Graduate School, 216 Administration Building, University of Memphis, Memphis, TN 38152. Have you submitted all transcripts to the Graduate School?

Students are required to take the General Record Exam (GRE) and submit scores to the Graduate School, 216 Administration Building, University of Memphis, Memphis, TN 38152. Please indicate the date on which you took or plan to take the GRE.

Volunteer Experience: Please list any volunteer SOCIAL WORK you have done.
    Agency Dates (Month/Year-Month/Year) Duties

Current Employer(s) and Employment History: Please list your current employer(s). You MUST also attach a resume listing all of the employment you have held in the past ten years beginning with the most recent. If unemployed, indicate activities/whereabouts. Please list in reverse chronological order.
    Agency Dates (Month/Year-Month/Year) Duties

How many paid years of social work experience do you have?

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Prior Convictions:
Have you ever been convicted of any offense other than a minor traffic violation?

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Ability to Practice Social Work:
In the past two years, have you had any general medical, mental health, or substance abuse conditions that could impair your ability to practice social work?

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References: List the names, phone numbers, and email addresses of the individuals you have asked to submit references. Reference forms will be be sent to the email addresses you provide here. At least one reference must be from a former faculty member. Two of the three must be from sources familiar with your volunteer, internship, or paid work experience. You may submit an optional fourth reference.

The reference form will be sent by email if a valid email address is listed in the column below. If your reference has already submitted his/her form on paper, write "submitted" in the email column.

If your reference works for the State of Tennessee and has an email address, we recommend that you ask the person for an alternative email address. Sometimes, our reference requests do not get delivered to State of Tennessee email addresses.
FirstLastEmailPhone Number

Under the Family Educational Rights Act of 1974, students are entitled to review their records, including letters of recommendation. It is your option to waive your right to review this recommendation, or you may decline to do so. If you waive your right to review your recommendation forms, these evaluations will be considered confidential by the University of Memphis and will not be available for your inspection should you be accepted for admission to this program. Please indicate below whether or not you intend to waive your right to view your references.

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Last Updated: 10/4/13