| First Name: |
|
| Middle Name: |
|
| Last Name: |
|
| Prior First Name.: |
|
| Prior Last Name: |
|
| Phone No. (home): |
|
| Phone No. (daytime): |
|
| Gender: |
Female
Male |
| Birth Date: |
(MM/DD/YYYY) |
| Birth City: |
|
| Birth State: |
|
| Social Security No. (REQUIRED) |
(please, no
hyphens.) |
| Are you a United States citizen?: |
Yes
No |
| If no, indicate country: |
|
| Visa type: |
|
| If you are an immigrant, give your Alien Registration Number: |
|
| Ethnic information(The University is required by Federal law to
request this information. Your response is voluntary.): |
|
| Mailing address: |
|
| Apartment No.: |
|
| City: |
|
| State: |
|
| Zip: |
|
| Permanent address: |
|
| City: |
|
| State: |
|
| Zip: |
|
| Email Address: |
|
| I am applying for: |
|
| In the year of: |
(YYYY) |
| I plan to attend the: |
|
| Enrollment status: |
|
| Name of last high school attended: |
|
| City: |
|
| State: |
|
| I attended high school from (date) : |
(MM/DD/YYYY) |
| I attended high school to (date) : |
(MM/DD/YYYY) |
| Date of high school graduation : |
(MM/DD/YYYY) |
| Have you earned a GED certificate?: |
Yes
No |
| If yes, when? : |
(MM/DD/YYYY) |
| Indicate when you took or plan to take college entrance exam - ACT : |
(MM/DD/YYYY) |
| SAT : |
(MM/DD/YYYY) |
| I wish to enroll in the following college or program.: |
|
| Major: |
|
| Have you previously applied to the University?: |
Yes
No |
| If yes, when? : |
(MM/DD/YYYY) |
| Have you previously attended State of the Art University in any status?: |
Yes
No |
| If yes, when? : |
(MM/DD/YYYY) |
| Are you presently enrolled in high school?: |
Yes
No |
| Are you presently enrolled in college?: |
Yes
No |
| I am presently enrolled in college, and my last term will be: |
|
| Are you currently on probation at any college or university?: |
Yes
No |
| If yes, enter name of institution.: |
|
| Date of probation. : |
(MM/DD/YYYY) |
| Have you ever been suspended from any college or university for any reason?: |
Yes
No |
| If yes, enter name of institution.: |
|
| Date of suspension : |
(MM/DD/YYYY) |
| Reason for suspension: |
Academic
Disciplinary |
| List below last college or university ever attended in any status. |
|
| Name of institution: |
|
| City: |
|
| State: |
|
| I attended from : |
(MM/DD/YYYY) |
| I attended through : |
(MM/DD/YYYY) |
| Degree received: |
|
| Credit hours earned(approx.): |
|
| Did your parents or legal guardian claim you as a dependent on federal income tax
returns in the immediate past tax year?: |
Yes
No |
| If yes, who claimed you?: |
|
| Are you a non-resident married to a state resident?: |
Yes
No |
| Have you ever attended this university while on a competitive or athletic
scholarship, tuition reciprocal agreement, or student exchange?: |
Yes
No |
| If yes, when : |
(MM/DD/YYYY) |
| Do you intend to maintain permanent state residence?: |
Yes
No |
| Are you a member or a dependent of a member of the US Armed Forces who is stationed
in this state?: |
Yes
No |
| |
|
