Graduate Certificate in Gerontology
Program Application Form

Before filling out this form, please carefully read the Graduate Certificate Program information page. Also, before you can be admitted to the Graduate Certificate Program, you must be admitted to the Wayne State University Graduate School. If you are not currently a Wayne State student, please submit an application for admission to the Graduate School before submitting this form. Application forms and more information on graduate programs for prospective students are available at the Graduate School's website.

Once you have been accepted to the Wayne State University Graduate School, my may apply for acceptance to the IOG Graduate Certificate program by typing the relevant information into this form and pressing the "Submit Application" button. Applications are not considered complete until the submission of a personal statement and letters of reference and the development of a plan of work during your personal interview with the Associate Director of Education.

Personal Information:

Name (Last, First, Middle Initial)

Student Number

Home Address	City	State	Zip Code
E-mail Address:

Home Phone

Business Phone

Place of Employment

Part Time
Full Time

Job Title and Responsibilities

List Degree(s) Previously Earned and the Awarding Institutions:

Degree	Institution(s)	Major	Date

Are you currently enrolled in a degree program at Wayne State University?

Yes No

If yes, please specify:

Degree	Major	Department

What is your student status?: Part Time Full Time

Term in which you expect to begin Certificate in Gerontology Program course work:

Term Year

Personal Statement: Briefly describe your interest in Gerontology and your reason for applying to the Graduate Certificate in Gerontology Program. What special experiences do you bring to this program that support or strengthen your interests in working in the field of aging? Your personal statement should be 1 to 2 pages in length and should be sent to the address below or e-mailed to j.mendez@wayne.edu.

Letters of Reference: Please have three letters of reference sent on your behalf: one from your academic advisor or someone who is knowledgeable regarding your academic abilities, and two from people who have worked with you and and, if applicable, know your work with older adults. The letters should be sent to the address below. Please enter the names of your references with their contact information:

Name	Phone	E-mail Address

Optional Information:

Birth Date: Sex: Male Female

Race/Ethnic Identification:

Course Work: A plan of work for your course work will need to be completed at your personal interview with the Associate Director of Education. A total of 12 credit hours are required.

Submission of your application may take a moment...please wait for confirmation.

Please send your personal statement and letters of reference to the following address, and remember to call or send e-mail to schedule a personal interview soon:

Jennifer Mendez, Ph.D.
Director of Education
Institute of Gerontology
Wayne State University
87 E. Ferry
Detroit, MI 48202
phone: (313) 577-2297
email: j.mendez@wayne.edu

Institute of Gerontology

Graduate Certificate in GerontologyProgram Application Form

Graduate Certificate in Gerontology
Program Application Form