Application for Project S.P.E.A.K.

Personal Information
Full Name: 
Maiden Name: 
Mailing Address: 
City: 
State:
Zip Code: 
Work Phone: 
Home Phone: 
Cell Phone: 
Email Address: 
Date of Birth: 
*Social Security Number: 
*Disclosure of your social security number (SSN) is voluntary. If you provide your SSN, it will be used for various administrative purposes at the University. If you do not provide your SSN, a student number will be assigned to you and you may experience a delay in services due to the time needed to match your file against files which us a SSN.
Sex:
Are you a current MSSU student?
Have you been approved for Junior Block?
Your Legal Residence: 
City/State: 
Country: 
Are you a Missouri resident?
If yes, how long have you lived in Missouri?
If one year or less, when did you move to Missouri? 
If you are not a Missouri resident, of which state are you a resident?
Are you a U.S. Citizen or a permanent resident?
College or University Enrollment History
List ALL accredited colleges and universities from which you have earned credit: College Name City/State Dates Attended Hours Earned Degree 
Employment History
Current Employer: 
(School District) 
Building Assignment and Address 
Principal’s Name: 
Teaching Certification: 
Current Grade Level Teaching: 
Do you currently hold Missouri Certification?
**Note: please provide a copy of your teaching certificate and transcripts with this application. Application not complete until all materials submitted.

Missouri Southern State University
Project S.P.E.A.K.
Taylor Hall, 232
3950 E. Newman Rd.
Joplin, MO 64801