ALL APPLICATION MATERIALS CAN BE MAILED TO:

Dakota State University

Office of Graduate Studies and Research
Heston Hall Room 309
820 N Washington Ave
Madison, SD 57042
Materials required to complete this application:
1. Application Form: A complete application form includes the application form and any program- specific application
materials required. (Please see individual program requirements).
2. Application Fee: A non-refundable application fee of $35 ($85 for international students), drawn on a U.S. bank, must
accompany the form. The check should be made payable to Dakota State University. If the application fee is not included, the
application will not be processed. The application fee cannot be waived or deferred and is non-refundable.
3. Transcripts: Official transcripts for all institutions from which you have earned degrees or expect to earn a degree as well as
any institution from which you have completed coursework that you want considered as part of your degree requirements. If
you have received any degree from a South Dakota Regental institution, you will not need to submit an official transcript for
that university. Transcripts should be sent directly to the Office of Graduate Studies and Research in a sealed envelope. The
registrar’s signature and the school seal must be across the sealed flap. Neither photocopies nor transcripts marked “student
copy” are acceptable. In unusual circumstance, an application with unofficial transcripts will be reviewed, but the official
transcript must be received prior to official admission.
5. Forms of Recommendation: Applicants must submit three forms of recommendation. If the recommendation forms are
included with the completed application, the recommendation should be sealed inside an envelope with the reference’s
signature across the sealed envelope flap to ensure confidentiality. Additional recommendation forms are available in the
Office of Graduate Studies and Research or on-line at http://www.dsu.edu/gradoffice/grad-forms.aspx. Three
recommendation forms are included in each admission packet that is mailed to prospective applicants.
6. Standardized Graduate Admission Test Scores: Applicants are required to take the GRE General test (See specific
programs for waiver criteria). International students must also take the TOEFL. Applicants should have the official test
scores sent directly to the Office of Graduate Studies and Research. The DSU code number for both tests: 6247.
7. Assistantship Form
Applicants who are requesting a graduate assistantship must complete and submit the assistantship form, including the skills
and abilities matrix form for specific programs. If you are applying for an assistantship, you must take the GRE.
Additional materials that International Students must complete:
1. Transcripts: English translation of transcripts, with a grade point average or overall percentage calculated and provided,
either on the transcript or in a notarized document. The credential must have an authorized signature clearly showing the date
of entry in the program and date of graduation. Under unusual circumstances, notarized or certified copies may be submitted
for evaluation at the time of application and will be accepted as official transcripts.
2. If you have an H1-B visa: please include a copy of your visa, passport and a letter from your employer.
3. Proficiency in English: to meet this requirement, the applicant must submit an official Test of English as a Foreign
Language (TOEFL) score or proof of an undergraduate or graduate degree from an accredited university in the United States.
A score of 550 on the paper-based test, 78 on the Internet-based test, and 213 on the computer-based test is required.
4. Finances: Submit official documentation showing that you have access to sufficient funds to cover all the necessary living
and tuition expenses for the duration of the program study. Along with the DSU Declaration and Certification of Finances form,
submit official bank statements, notarized support letters, or some other official affidavit of support.
5. Application fee: $85 Note: International students also pay a one-time International student fee their first semester at DSU,
in addition to tuition and fees.
 APPLICATION FOR GRADUATE ADMISSION

Application materials can be sent to the DSU, Office of Graduate Studies & Research, 309 Heston Hall, 820 N. Washington Ave., Madison, SD
57042. Before an application can be processed all items listed in the application checklist (page 3 of this form) must be on file.

Program Information (degree for which you are applying)

□ MBA in General Management (MBA) Term of Entry: SU 20 _____ FA 20____ SP 20____
□ MS in Information Systems (MSIS) Term of Entry: FA 20_____SP 20____
□ MS in Health Informatics (MSHI) Term of Entry: SU 20 _____ FA 20____ SP 20____
□ MS in Information Assurance and Computer Security (MSIA) Term of Entry: FA 20_____
□ MS in Educational Technology (MSET) Term of Entry: SU 20 _____ FA 20____ SP 20____
□ Doctor of Science (D.Sc.) in Information Systems Term of Entry: FA 20_____

□ Full Time (minimum 9 cr. hrs. per semester) □ Part Time (less than 9 cr. hrs. per semester)
PERSONAL INFORMATION

NAME: _______________________________________________________________________________________________________________
Last Name First Name Middle Suffix (Jr., Sr., III, etc.)

Former Name: _______________________________________

(Other names under which any documents might arrive)

Social Security Number _________- _____ - ________ Date of Birth (use numbers): _____/_____ /_____
mm dd yy

CURRENT ADDRESS (Present mailing address)

_______________________________________________________________________________________________________________________
_
Number and Street City State Zip code Country

Local Telephone Number (________) ______________________ Work/School Telephone Number (________) ______________________

Electronic mail address (e-mail) _________________________________________________________________

Current address, phone, and email valid until ____________________________________

PERMANENT ADDRESS (if different from above)

______________________________________________________________________________________________________________________________________
_
Number and Street City State Zip code Country

(________) ________________________
Phone Number at Permanent Address

Person to contact in case of an emergency ______________________________________________ Phone Number _________________________

CITIZENSHIP AND RESIDENCY

Are you a citizen of the United States? □Yes □ No If yes, are you a resident of South Dakota? □Yes □ No
Are you a resident of MN? □Yes □ No
If you are not a U.S. citizen;
What is your country of citizenship? ________________________________________
What is your country of birth? _____________________________________________
• Are you a permanent resident? □ Yes □ No Please attach a copy, front and back, of your green card
form I-555
If you are not a U.S. citizen or permanent resident, what is your visa status? ________
(If H1B, attach a copy of your visa, passport, and letter of approval from employer.)
What is your native language? _______________________ How many years have you spoken or studied English? ______________
Information Request
The information requested below is used to comply with Title VI of the Civil Rights Act of 1964. As an applicant, responding to these questions is
optional and your response will in no way affect your admission. However, we are asking for the information now, to avoid sending a separate
request after admission. We use the data in aggregated form only, to comply with federal requirements.
Gender: □ Male □ Female
Ethnicity: □ Hispanic/Latino □ Non-Hispanic/Latino
Race: We invite you to designate any minority group status with which you identify, check all that apply.
□ American/Alaska Native □ Black or African American □ White □ Asian □ Hawaiian/Pacific Islander
ACADEMIC HISTORY
Baccalaureate degree:
_________________________________________________________________________________________
_
Institution Location Dates attended Degree Earned Date Earned

Undergraduate Major ______________ Undergraduate Minor ______________ GPA or equivalent (class, division or %) __________
(Do not convert % to GPA)
Master’s degree:
_________________________________________________________________________________________
_
Institution Location Dates attended Degree Earned Date Earned

Official transcripts for all institutions from which you have earned degrees or expect to earn a degree should be sent directly to the
Office of Graduate Studies and Research or enclosed in a sealed and signed envelope and submitted with this application.

Please list in reverse chronological order all institutions of higher education you have attended or are currently attending in addition to
the listed above. You may attach additional pages if necessary.
Location or Dates Attended Degree, Certificates, Date Earned or
Name of Institution Branch From To credits earned Expected Major Field

ASSISTANTSHIP
Are you applying for an assistantship? □Yes □NO If yes, complete and attach the Application for Assistantship Form.

REQUIRED STANDARDIZED TESTS: Required standardized tests and waiver opportunities are program specific. Please refer to
specific program admission requirements before completing the next section. TOEFL is required for all international students whose native
language is not English. All test scores must be current.

GRE (no more than 5 years old)

Date Taken: _______________ OR Expected Test Date and Site: _______________

General Test Score: Verbal: ________ Quantitative: __________ Cumulative (V+Q) __________ Analytic Writing ________
Are you requesting a waiver (see admission requirements for acceptable conditions)? □ Yes □ No
Criterion or Provide explanation: _____________________________________________________________________________________________

TOEFL (no more than 2 years old; for international/ESL students)

Date Taken: ______________ TOEFL Score: ________________________ OR Expected Test Date and Site: __________________________

ACADEMIC HONORS:
In the space below, briefly describe any academic honors (prizes, scholastic recognition, scholarships/fellowships, membership in honorary
societies), published works, and leadership activities you consider significant to your graduate study. Continue on separate sheet if necessary.
_________________________________________________________________________________________
_________________________________________________________________________________________
__
_________________________________________________________________________________________
_

EMPLOYMENT HISTORY/PROFESSIONAL EXPERIENCE

Please list in reverse chronological order full-time, part-time, and summer employment for the last 5 years.
Dates Employed
Name and Address of Employer Nature of Work/Experience Month/Year to Month/Year

Attach additional sheets if necessary.

REFERENCES
Please list the three persons who are familiar with your educational or professional work and who have agreed to serve as references and then please
forward a recommendation form to each of these references. These individuals should be able to evaluate your probable success as a graduate
student. Completed forms should be sent directly to the Office of Graduate Studies and Research or enclosed in a sealed and signed envelope with
this application form.
NAME ADDRESS POSITION

Application checklist, please indicate:

□ I am enclosing/have requested one official transcript for all institutions from which I’ve earned or expect to earn a degree
(except SD Regental Universities).
□ I am enclosing/have requested one official transcript for institutions from which I’ve completed coursework that I want
considered as part of my degree requirements (except SD Regental Universities).
□ I have requested an official score report for the GRE general test and TOEFL to be sent to DSU or I am planning to take the
GRE/TOEFL.
□ I am enclosing/have asked 3 references to submit recommendation forms.
□ I have enclosed the $35.00 application fee ($85 for international students).
□ International student with H1-B visa; I have enclosed/have requested a copy of visa, passport, and letter of approval from
employer.
□ International students: I have enclosed the DSU Declaration and Certification of Finances form.
□ International student with Permanent Residency: I have enclosed a copy of form I-555.
I certify that the information on this form is complete, true and accurate. I understand that any misrepresentation or omission of facts
in my application will justify denial or cancellation of admission to the university, before or after enrollment. I understand that the
application and all credentials submitted in support of the application become the property of the University and will not be returned
or forwarded to another institution. I also understand the information in the application will be shared with all members of the
admission committee and assistantship committee (if assistantship is requested).

Signature of Applicant Date

Program Information
Please tell us how you learned about the academic program for which you have applied.
□ DSU listing in a graduate school guide or directory: _______________________________________________________________
□ DSU graduate program listing in a Web Guide: ___________________________________________________________________
□ Internet Search __________________ □ Friend
□ I graduated from DSU □ Professor at current school
□ DSU Graduate Program alumnus □ DSU informational mailing
□ DSU Website □ Other: __________________________________________
 Additional Information Required For
D.Sc. in Information Systems Applicants
(This page and required additional pages must be included with your application.)

I. Statement of Purpose:
On a separate sheet; provide a brief essay (1-2 pages single spaced, 11 pt. Times New Roman, typed or
computer-processed) of your interests, professional plans and career objectives. In your statement,
make sure you address the following:
o Why do you want to get a doctoral degree in information systems?
o What are your research interests?
o Why are you interested in these research topics?
o Do you have the motivation/perseverance to complete the degree?
o What qualities and experiences do you have that will contribute to your success in the program?
o What do you plan to do with your degree once you have it?

II. Publications (if any, include a separate sheet if necessary, and a copy of a sample publication):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

III. Certifications:
Please list any current certifications (or licenses) you hold and provide relevant dates (received/expired). Include
copies of the certificates with your application.
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________

Briefly tell us why you think these are relevant to the program (must be provided for to be reviewed).
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

IV. Certification and Signature

I certify that the information on this form is complete, true and accurate. I understand that any
misrepresentation or omission of facts in my application will justify denial or cancellation of admission
to the university, before or after enrollment. I understand that the application and all credentials
submitted in support of the application become the property of the University and will not be returned or
forwarded to another institution. I also understand the information in the application will be shared with
all members of the admission committee and assistantship committee (if assistantship is requested).

Signature of Applicant: ___________________________________________________________

Date: _______________________________
 RECOMMENDATION FORM

TO THE APPLICANT:
Complete the section on personal information and forward the form to three individuals under whom you have studied or worked
and/or who are able to assess your qualifications for graduate study. Instruct this person to return the recommendation to you in a
sealed envelope, signed across the flap. If the individual prefers to send it to our office directly, it should be sent to the: DSU Office of
Graduate Studies and Research; Heston Hall Room 309; Madison, SD 57042. You must submit three recommendation forms.

PERSONAL INFORMATION:

Name_____________________________________________________________________________________________________
(Last Name) (First Name) (Middle Name)

Address____________________________________________________________________________________________________
Number and Street City State Zip code

(_____)____________________ (______)_______________________ ___________________________________________

Local Telephone Number Work Telephone Email

INTENDED DEGREE:
□ MBA in General Management (MBA)
□ MS in Information Systems (MSIS)
□ MS in Health Informatics (MSHI)
□ MS in Educational Technology (MSET)
□ MS in Information Assurance and Computer Security (MSIA)
□ Doctor of Science (D.Sc.) in Information Systems
UNDER THE PROVISIONS OF THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT:

____ I have retained my right to access to this recommendation.

____ I have waived my right to access to this recommendation.

Signature of Applicant Date



TO THE PERSON MAKING THIS RECOMMENDATION:

The applicant has given your name as a reference. The university would appreciate your cooperation in promptly providing feedback
regarding the applicant’s aptitude for graduate study.
1. How long have you known the applicant? _________________

2. During this time, the applicant was a/an:

 undergraduate student  advisee of mine
 graduate student  supervised by me at work
 departmental assistant  other _____________________________
 assistant of mine

3. Do you think the applicant is sufficiently prepared to undertake (or continue) graduate work?
 Yes  No  Uncertain
Explain:_________________________________________________________________________________________________
________________________________________________________________________________________________________
 ________________________________________________________________________________________________________
________________________________________________________________________________________________________

4. Based on the students you have known in the same field and with the same experience and training, how do you rate the
applicant?
 Best in my experience  Highest 5%  Next highest 5%  Above average (15-25%)  Average (upper 50%)
 Below average (lower 50%)

5. Please rate the applicant on the following characteristics (1: Weak, 9: Extremely strong)
Not able
Characteristic to
evaluate
research aptitude 1 2 3 4 5 6 7 8 9
originality 1 2 3 4 5 6 7 8 9
acceptance of responsibility 1 2 3 4 5 6 7 8 9
emotional maturity 1 2 3 4 5 6 7 8 9
ability to work independently 1 2 3 4 5 6 7 8 9
writing skills 1 2 3 4 5 6 7 8 9
speaking skills 1 2 3 4 5 6 7 8 9
technical/computer skills 1 2 3 4 5 6 7 8 9
6. Please use this space to discuss the applicant’s strengths and weaknesses, creative promise, leadership ability, maturity, character
and intellectual capacity. Please attach additional pages if necessary.

Name (please print or type) ______________________________________________Title______________________________

Institution/Organization/Business___________________________________________________________________________

Address_____________________________________________ Phone number_______________________________________

Email: _________________________________________________________________________________________________

Signature ___________________________________________________________Date ________________________________

Please sign this form, seal it in an envelope, sign your name over the flap, and return to the applicant to be included in the
application packet. If you prefer, your recommendation can also be sent directly to the DSU Office of Graduate Studies and
Research, 309 Heston Hall, 820 N Washington Ave, Madison, SD 57042.

If you have any questions, please contact the Office of Graduate Studies and Research at (605) 256- 5799 or email us at
[email protected].
 REQUIRED IMMUNIZATION FORM
(Not required of on-line/distance students.)

IMMUNIZATION REQUIREMENTS FOR REGISTRATION

Due to regulations mandated by the Board of Regents, all students, who reside on campus or receive instruction on campus, must
document their immune status for measles, mumps, and rubella. “Proof of two doses of measles, mumps, and rubella vaccine, or
of separate vaccinations against all three diseases, or of the presence of immune antibody titers against measles, mumps, and rubella
shall be required.” Students who fail to provide the required, signed proof of immunizations shall not be permitted to register for or to
attend classes at any state institution until they are in compliance. Students born before January 1957 are exempt from providing
immunization documentation.

Name________________________________________________BirthDate______/______/_______
Last First Middle Mo. Date Year

Soc. Sec. #______/______/_______ Phone (_____) _______________Cell (_____) ________________

Address______________________________________________________________________
Address City State Zip Code

REQUIRED IMMUNIZATIONS – Must be filled out and signed (below) by a Health Care Provider.
Date of 1st Measles, Mumps, Rubella Immunization Date of 2nd Measles, Mumps, Rubella Immunization
(Must be given after age 12 months) (Must be given at least 30 days after 1st MMR)

1st MMR_______/________/_________ AND 2nd MMR_______/________/_________

OR Separate Immunizations:

#1 Rubella_______/________/_________ AND #2 Rubella_______/________/________

#1 Rubeola_______/________/_________ AND #2 Rubeola_______/________/________

#1 Mumps_______/________/_________ AND #2 Mumps_______/________/_________

OR Titers:

Rubella Titer Date_______/________/_________ POSITIVE Result__________ Attach copy of Lab result

Rubeola Titer Date_______/________/________ POSITIVE Result___________Attach copy of Lab result

Mumps Titer Date_______/________/_________ POSITIVE Result __________ Attach copy of Lab result

Signature__________________________________________ Date ___________________________

(Must be signed by a Nurse, P.A., or a Physician)

Address_____________________________________________________________________
Address City State Zip Code
MEDICAL EXEMPTION TO IMMUNIZATION REQUIREMENT

I certify that it would be harmful to this student’s physical health to be immunized against measles,
mumps, and rubella.

Reason for Exemption: _________________________________________________________

Check one: ___________ Permanent Exemption

___________ Temporary Exemption – Date to be released: ___________________
Month Day Year

Physician’s Signature ______________________________________Date: _____________________

(Must be signed by a Physician)

RECOMMENDED IMMUNIZATIONS (Not required for registration)

Name: _____________________________________________________________________________
Last First Middle

Tetanus-Diphtheria (Td) booster_______/________/_________or Tdap ______/______/______

Hepatitis B #1______/______/______ #2 ______/______/_______ #3 ______/______/_______

Meningitis _______/________/________

Varicella (Chicken Pox) Vaccine #1______/_______/_______ #2_______/_______/_______

OR
Chicken Pox Disease (date) _______/________/_________

Tuberculosis – PPD (Mantoux) within the last year ______/_______/______ Results: ________
 APPLICATION FOR ASSISTANTSHIP

NAME: _______________________________________________________________________________________________________________
Last Name First Name Middle Name Suffix (Jr., Sr., III, etc.)

Social Security Number _________- _____ - ________

(Optional – may be used to help with identification)

CURRENT ADDRESS (Present mailing address)

______________________________________________________________________________________________________________________________________
_
Number and Street City State Zip code Country

Local Telephone Number (________) ______________________ Work/school Telephone Number (________) ___________________________

Electronic mail address (e-mail) _____________________________________________________________________________________________

Current address, phone, and email valid until? _____________________________________________

CITIZENSHIP AND RESIDENCY

Are you a citizen of the United States? □Yes □ No If yes, are you a resident of South Dakota? □Yes □ No
Are you a resident of MN? □Yes □ No

If you are not a U.S. citizen;

What is your country of citizenship? ____________________________
What is your country of birth? ___________________________
• Are you a permanent resident? □ Yes □ No Please attach a copy, front and back, of your green card
form I-555

If you are not a U.S. citizen or permanent resident, what is your visa status? _______________
(If H1B, attach a copy of your visa, passport, and letter of approval from employer.)
What is your native language? _________________________ How many years have you spoken or studied English? _____________________

ACADEMIC HISTORY
Baccalaureate degree:
___________________________________________________________________________________________________________
_
Institution Location Dates attended Degree Earned Date Earned

Undergraduate Major ______________ Undergraduate Minor ______________ GPA or equivalent (class, division) ______________

Master’s degree:
___________________________________________________________________________________________________________
_
Institution Location Dates attended Degree Earned Date Earned

Official transcripts for all institutions from which you have earned degrees or expect to earn a degree should be sent directly to the
Office of Graduate Studies and Research or enclosed in a sealed and signed envelope and submitted with this application.

Please list in reverse chronological order all institutions of higher education you have attended or are currently attending. You may attach additional
pages if necessary.
Name of Institution Location or Dates Attended Degree, Certificates, Date Earned or Major Field
Branch From To credits earned Expected
REQUIRED STANDARDIZED TESTS: TOEFL is required for all international students whose native language is not
English. All test scores must be current.

GRE (no more than 5 years old)

Date Taken: _______________ OR Expected Test Date and Site: _______________
General Test Score: Verbal: __________ Quantitative: __________ Cumulative (V+Q) __________ Analytic Writing __________
TOEFL (no more than 2 years old)
(For international/ESL students)
Date Taken: ______________ TOEFL Score: ________________________ OR Expected Test Date and Site: __________________________

ACADEMIC HONORS:
In the space below, briefly describe any academic honors (prizes, scholastic recognition, scholarships/fellowships, membership in honorary
societies), published works, and leadership activities you consider significant to your graduate study. Continue on separate sheet if necessary.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

REFERENCES
Please list the three persons who are familiar with your educational or professional work and who have agreed to serve as references (please forward
a recommendation to each of these references. These individuals should be able to evaluate your probable success as a graduate student. Completed
forms should be sent directly to the Office of Graduate Studies and Research or enclosed in a sealed and signed envelope.
NAME ADDRESS POSITION

Are you currently employed in the United States? □ Yes □ No

Name of employer? _____________________________________________ Number of hours per week? _____________

If you are seeking an assistantship for the MSIS, MSIA, or the D.Sc. program you must also complete the following skills
matrix:
SKILLS, EXPERIENCES, RESPONSE COMMENT OR EXPLANATION
ABILITIES
WRITING SKILLS:
Proficiency (1-5 with 1= low-and 5 = high) * If 4 or 5, attach a one-page sample
Published? YES NO (CIRCLE ONE)

If yes, list publications here →

RESEARCH INTERESTS

List interests here →

RESEARCH EXPERIENCE YES NO (CIRCLE ONE)
Were you a Principal Investigator or
YES NO (CIRCLE ONE)
Co-PI?
Have you published? YES NO (CIRCLE ONE)

If yes, list publications here →

LIBRARY RESEARCH EXPERIENCE YES NO (CIRCLE ONE)

If yes, list Tools/Indices used here →

LAB RESEARCH / EXPERIENCE YES NO (CIRCLE ONE)
What kinds of labs?
List here →
Equipment used:
List here →
TEACHING EXPERIENCE YES NO (CIRCLE ONE)
Level (e.g., K-12, undergraduate,
graduate students)
Subject(s)
List here →
Number of Years
Number of students per class
SUPERVISORY EXPERIENCE YES NO (CIRCLE ONE)
Your Title
Number of people supervised?
Was this a paid position? YES NO (CIRCLE ONE)
 Please complete the following computer experience checklist, describing your software and hardware experience:

PROFICIENCY
APPLICATION SOFTWARE (From 0-5 EXPLANATION
AND HARDWARE with Include specific software packages where
EXPERIENCE 0 = no experience & applicable. Provide a resume for experience. List
5 =expert) any training or certifications.
MODELING TOOLS List below:

PERSONAL PRODUCTIVITY List below:

SOFTWARE
Word Processing
Spreadsheet
Presentation
DBMS
Other
PROGRAMMING LANGUAGES List below:
Visual Basic
C++
COBOL
JAVA
HTML
Other
STATISTICAL PACKAGES List:

INTERNET List below:

Search
Interpret Results of a search
Web Page Design
What tools?
HARDWARE List below:
PC Hardware Architectures
Concepts of OS – Hardware Interfaces
PC Hardware Installation
OPERATING SYSTEMS List:

PLATFORMS List:

OTHER SOFTWARE SYSTEMS List:

PLEASE ATTACH A RESUME.

CERTIFICATION AND SIGNATURE

I certify that the information on this form is complete, true and accurate. I understand that any misrepresentation or omission of facts in my
application will justify denial or cancellation of admission to the university, before or after enrollment. I understand that the application and all
credentials submitted in support of the application become the property of the University and will not be returned or forwarded to another institution.
I also understand the information in the application will be shared with all members of the assistantship committee.

Signature ___________________________________________________ Date __________________________