Division of Continuing Studies

Temporary Graduate Admission Form

College of Education and Public Policy

Indiana University - Purdue University Fort Wayne

Please note: If you are not currently in the IPFW system, an IPFW staff member will be contacting you via phone for
your complete social security number. IPFW is required to report social security numbers to the Federal Government.


Application for Teacher Workshops
Today's Date:
Name (First, Middle, Last):
Maiden Name (if applicable):
Social Security - Last 4-Digits (0000):
Mailing Address:
City, State, Zip:
Permanent Address: (if different from above)
City, State, Zip:
Home Phone : (000) 123-4567
Daytime Phone :(000) 123-4567
Email Address:
Date of Birth (mm/dd/yyyy):


Citizenship Status :
Ethnicity: (required by State & Federal Law)
Legal Residence:   
Where have you been living for the past 12 months?      
Country of Citizenship:
Alien Registration Number:


Academic Unit/Department :
Objective: Check One (Temporary students receive NO Financial Aid)
Intended Major/Licence Renewal Area:
Are you currently enrolled?
Have you attended an IU graduate school?
If yes,   
Do you intend to complete M.S. degree at Fort Wayne campus?
What semester are you planning to register for classes?        



College/University Previously Attended  
College/University City & State From (Mo/Yr) To (Mo/Yr) Degree/Date


*****For Office Only*****
Entry Type :
Entry Term :
Program :
Major :
Concentration :
Student Type :
Residency :
Initials :
Reviewed Date :


Please read the following carefully:

I understand that this form may be used for one of two purposes:

1. To permit me to enroll for maximum of six semester hours of graduate work within a five (5) year time period for license renewal.

2. To permit me to take graduate credits for one semester prior to admission to Graduate School.

Course work taken under temporary status will not automatically be included in a future graduate degree program.