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Certificate in Technology and
Communication Application Form


To register, please provide the information below and then click
the REGISTER NOW button. Use the tab key to move through the form. Fields in RED must be completed for your application to be reviewed.

First Name: Middle Initial:
Last Name:
Personal ID Number (PID):             Look-up your University PID
Date of Birth: (Format: mm-dd-yyyy)
Address(line 1):
Address(line 2):
City: State: Zip:
Country:
Email:
Occupation:
Daytime Phone:
Evening Phone:
FAX:
Employer:
Title:
Employer's Address:
City: State: Zip:
Country:


                      Colleges Attended                Major                       Year

Associate's Degree
(format: yyyy)
Bachelor's Degree
(format: yyyy)
Master's Degree
(format: yyyy)
Doctorate or Professional Degree
(format: yyyy)
Undergraduate GPA:
TOEFL Score: (International Students Only)
Years of experience in journalism or mass communication?
Number of years since enrolled in a higher education program?
Previous experience with online courses?
Please tell us why you are pursuing this certificate:(250 words or less)
Please describe your plan for completion of the program (e.g. the order and semesters in which you plan to take the three courses required to complete the certificate).
Do you plan to enroll in a graduate degree program after completing this certificate?

How did you find out about the program?
Brochure/Postcard
E-Mail
Friend/colleague
School Web site
Radio
Other distance learning Web site
Search engine(Google, Yahoo, etc.)
Fax
Other

What type of Internet connection do you have?
Dial-up
DSL or Cable Modem
LAN
Don't know
Have you ever used Blackboard Course Management System?
Have you ever visited an online discussion forum or bulletin board?
Gender:
Race/Ethnicity:
Are you a student, faculty member, or staff member in the UNC System?
Are you a graduate of the School of Journalism and Mass Communication?

Campus Safety Questions:
The University requires answers to the following questions before admittance in any UNC-Chapel Hill program.
Your "yes answer to one or more of the following questions will not necessarily preclude your being admitted. However, your failure to provide complete, accurate, and truthful information will be grounds to deny or withdraw your admission, or to dismiss you after enrollment.
For the purpose of the following six questions, "crime" or "criminal charge" refers to any crime other than a traffic-related misdemeanor or an infraction. You must, however, include alcohol or durg offenses whether or not they are traffic related.
1. Have you been convicted of a crime?
2. Have you entered a plea of guilty, a plea of no contest, a plea of nolo contendere, or an Alford plea, or have you received a deferred prosecution or prayer for judgment continued, to a criminal charge?
3. Have you otherwise accepted responsibility for the commission of a crime?
4. Do you have any criminal charges pending against you?
5. Have you ever been expelled, dismissed, suspended, placed on probation, or otherwise subject to any disciplinary sanction by any school, college, or university?
6. If you have ever served in the military, did you receive any type of discharge other than an honorable discharge?
If you answered "yes" to any of the six questions above, please explain the circumstances below.
You must promptly notify us in writing of any criminal charge, and disposition of a criminal charge, or any school, college or university disciplinary action against you, or any type of military discharge other than an honorable discharge that occurs at any time after you submit this application. Your failure to do so will be grounds to deny or withdraw your admission, or to dismiss you after enrollment.
In order to complete your application, we will need a copy of your resume and undergraduate transcript. (If you received your undergraduate degree from UNC-Chapel Hill, you do not need to submit a transcript.) Please send your resume and transcript to hutaff@email.unc.edu or mail to:
Maggie Hutaff
School of Journalism and Mass Communication
UNC-Chapel Hill
Campus Box 3365
Chapel Hill, NC 27599-3365.

We may ask that you voluntarily provide your Social Security Number with the understanding that it will be used only as an identification number for internal record keeping and data processing operations at the University of North Carolina at Chapel Hill. Admission to this program is without regard to race, sex, national origin, color, religion, handicap, age or veteran's status. If you have any questions about this program or registration, please call (919) 843-9471 or send email to hutaff@email.unc.edu.