Canisius College

Graduate Programs in Education
Application for Readmission

All fields in bold are required.

Last 4 Digits of Social Security/Insurance Number:
Canisius Student ID (if known):
First Name:
Middle Name:
Last Name:
Maiden Name (if applicable):
Street Address (Apt/P.O. Box if applicable):
City:
State/Province:
Zip/Postal Code:
Country:
Daytime Telephone Number (including area code xxx-xxx-xxxx):

If you have a Cell Phone Number, please list it here even if you have listed it above (including area code xxx-xxx-xxxx):

U.S. Citizen:		Yes No
If no, list country of citizenship

U.S. Permanent Resident:		Yes No

Date of Birth (mm/dd/yyyy):
Email Address:
Verify Email Address:

Academic Program of Interest:

Term of Entry:

Please state your educational and career goals. Indicate what you plan to accomplish by re-enrolling in the graduate School of Education and Human Services.


Have you ever been convicted of a felony or misdemeanor (except a traffic violation)?		Yes No
If yes, give details:


I certify that the information which I have given on this page is complete and true to the best of my knowledge. I agree that if I am accepted for admission, I shall comply with all rules and regulations of the college, which may be in effect or which shall be put into effect while I am a student:
Yes No

Graduate Education