Application for Admission Worsham College of Mortuary Science Step 1 of 6 16% Personal InformationApplicant's Name* First Name Last Name Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email Address* Desired Course Delivery / Starting Date*Please Select Delivery Method / Starting DateOn-Campus Student - March 2020Online Student - May 2020Are You Interested In Living / Working at a Funeral Home during school year? Work at Funeral Home Live at Funeral Home Not Interested at this time I am a resident of Illinois 30 days prior to first day of class.* I certify I intend to have my embalming cases:At the Medical Examiners Office with the SchoolAt A Local Funeral HomeIf known, what is the name of the funeral home you intend to perform your embalming case work Personal Information - Part 2GenderGenderMaleFemaleDate of Birth*Place of Birth*If outside of the United States - Country of Birth Are you of Hispanic, Latino or Spanish origin?Are you of Hispanic, Latino or Spanish origin?YesNoWhat is your race?What is your Race?American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or more racesPrefer to not discloseMarital StatusMarital StatusSingleMarriedWidowedDivorcedSeperatedLast 4 Digits of Social Security Number*Last 4 Digits of Social Security Number Worsham College of Mortuary Science does not discriminate on the basis of race, color, religion, gender, sexual orientation, marital status, age, national origin/ancestry, disability, family relationship or any other protected status in accordance with applicable law. The college's commitment to nondiscrimination applies to curriculum activity and all aspects of operation of the college. Contact Information / Work HistoryParent / Guardian First Name Last Name Address of Parent / Guardian Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone of Parent / GuardianEmergency Contact First Name Last Name Address of Emergency Contact Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone of Emergency ContactName of Current EmployerAddress of Current Employer Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone of Current EmployerCurrent Employer Supervisor's Name First Name Last Name Are you related to anyone involved in Funeral Service?*YesNoWhat is your relationship to the family member in funeral service and their name(s)?(Mother Mary Smith, Uncle Bob Smith, etc.) Have you previously attended a funeral service program?*YesNoWhat is the name of the Mortuary College you previously attended?How did you learn about the Worsham College Mortuary Science program? Online Current/Former Student Friend College Fair Funeral Director's Convention College Fair / Guidance Counselor Do you have any funeral service experience?*YesNoHow many months have you worked in funeral service?Please enter a number from 0 to 100. Education BackgroundHigh School Completion*Select from listDiplomaGEDHome schooledOfficial high school transcripts will need to be sent to the school prior to acceptance.What is the highest level of college education attained?*Select from ListNot ApplicableSome College CreditAssociates DegreeBachelors DegreeAdvanced Degree (Masters. PhD)I have completed this many hours of college creditPlease enter a number from 0 to 200.Official Sealed College transcripts will need to be sent to the school prior to acceptance.Name of College 1Address of College 1 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Name of College 2(If applicable)Address of College 2(if applicable) City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Name of College 3(If applicable)Address of College 3(if applicable) City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Background InformationAre You a Veteran of the US Armed Forces?YesNoPlease attach your discharge paperwork DD-214Have you been convicted of a criminal offense in any state or federal court (other than minor traffic violations)?YesNoPlease attach a statement of each conviction including date and place of conviction, nature of offense and if applicable, the date of discharge from any penalty imposedHave you ever been denied a professional license or permit or priviledge of taking an examination, or had a professional license or permit disciplined in any way by any licensing authority in Illinois or elsewhere?YesNoWhich state do you intend to practice Funeral Service? AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Are you aware of the state educational requirements for this state?YesNot sureHave you fulfilled the prerequisite requirements for this state?*YesNot sure Application AttachmentsPersonal Essay*In 500 words or less, explain why you have selected funeral service for your career. Personal Essay*In 300 words or less, explain why online education is the right fit for you. 1st Letter of RecommendationSubmit a letter of recommendation from an individual familiar with your work performance and/or academic ability.You may also have the recommendation letters mailed directly to the campus c/o Registration Office.2nd Letter of RecommendationSubmit a letter of recommendation from an individual familiar with your work performance and/or academic ability.You may also have the recommendation letters mailed directly to the campus c/o Registration Office.Application Fee* Price: $50.00 Total Charge $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name By checking the box below, I certify the information contained in this application to the best of my knowledge is correct.* I Certify NameThis field is for validation purposes and should be left unchanged.