This
form will be submitted to: Arkansas Tech University Office of Graduate
Studies
* Indicates required field
For assistance completing application call
479-968-0398 8:00 - 5:00 CST
Social Security
Number -- *
Legal
Name-Last *
First *
Middle *
E-mail
Former Name 1
Former Name 2
Former Name 3
Permanent Home Address
Number/Street/Apt or
Route/Box *
City *
State *
Zip Code *
County *
Home Phone: () -
Day or Work Phone: () -
Are you a legal Arkansas resident? * How long have you lived at your
current address? mm/yy *
If less than 6 months, list previous addresses
(Street/City/State/Zip) For the past six months and how long you lived
at
each:
Local Address (if
different from permanent home address)
Number/Street/Apt or
Route/Box
City
State
Zip Code
County
Home Phone: () -
Day or Work Phone: () -
Emergency Contact
Last Name
First Name
Relationship
Number/Street/Apt or
Route/Box
City
State
Zip Code
County
Day or Home Phone:() -
Home Phone: () -
Personal
Information
Date of Birth (mm/dd/yy)://*
Gender:**
Ethnic Origin:
**
Resident Status*
If you are a Resident Alien (Immigrant) the
following information is required: Card Number Date Issued (mm/dd/yy): / / Country of Citizenship
Academic
Information
Are you seeking a degree? *
What is your intended Major?
Classification: * Term
*
High School Attended:
mm/yy. Graduated: /
mm/yy Earned GED:/
Location of High School: City/State/Zip//
List all other colleges and /or universities
attended:
School Name
Location (City/State)
Dates Attended
Hours Earned
Hrs Currently Enrolled
Degrees Earned
UNDERGRADUATE*
GRADUATE
Are you attending college now? *
University Name:
Are you eligible to return to the last school you
attended?
Do you hold (or eligible for) a standard teaching certificate?
Residence
Life
Housing : Full-time students under twenty-one
years of age must live in campus housing unless they are residing with
parents, grandparents, brother or sister over twenty one, or
spouse.
What are your housing plans ?
Will you be requesting accommodations made available through
the Americans With Disabilities Act ? *
Are you registered with the selective service?
If no are you :
It is my understanding that I will not be considered for admission to
Arkansas TECH University until I have submitted all credentials specified. I
further agree to inform the Office of Graduate Studies of any change in plans to
attend the University. I certify that none of the information requested on this
form is false. I understand that withholding or submitting inaccurate
information will make me ineligible for admission and enrollment and subject to
administrative withdrawal.
By marking the following box you are agreeing the above information
is true and correct to the best of your knowledge. * I
agree.
**Voluntary information to be used in a
nondiscriminatory manner consistent with applicable civil rights laws for
reporting and statistical purposes only and cannot affect your eligibility
for admission.
This form will be
submitted to: Arkansas Tech University Office of Graduate
Studies
