A-23 UNM Prospective EDAG Information Sheet

1. Hello Prospective Student for the Educational Diagnostician Preparation Program:

Thank you for your interest in the EDAG Program. Id be happy to talk with you. Prior to talking, it would be most useful if you would fill out this electronic Information Sheet. Please e-mail me at collierm@unm.edu and tell me when you completed this.

I look forward to talking with you about your interest in the EDAG Program.

Margo Collier, PhD
Associate Professor
Educational Diagnostician Program Coordinator
Department of Special Education
University of New Mexico
2. Name
3. Best phone or cell at which to reach you
4. Most frequently checked email address
5. Undergraduate degree
6. Date graduated/Will graduate
7. Degree earned
8. University
9. Field of study
10. Graduate degree
11. Date graduated/will graduate
12. Degree earned/earning
13. University
14. Field of study
15. Do you have a teaching license?
16. If yes, how many years have you taught?
17. Other professionally related years of work:
18. Are you licensed in this area of work?
19. How many years have you worked in this area?