Admissions Form

First Name:		Middle Name:		Last Name:		Social Security Number: - -
Applying For:		One course only? Yes No		Summer only? Yes No		Email address:
Gender: Male Female		Date of Birth (MM/DD/YYYY): / /		Church preference (optional):		Military Vet? Yes No
Are you a United States citizen? Yes No		If no, are you lawfully present in the U.S.? Yes No		If not a U.S. citizen, please provide your Alien Number: A:
Are you Hispanic or Latino? Yes No		Race - Which best describes you? Choose one or more of the following categories. American Indian or Alaska Native Asian Black or African American Native Haiwiian White
Type of degree you are seeking: Associates Bachelors Non-degree What subject do you plan on majoring in?		Henderson classification: Freshman Sophomore Junior Senior Certification		You plan to attend classes: On-campus Off-campus (All transcripts must be on file at HSU for on-campus) If off campus, what location?
Have you previously applied to Henderson? Yes No		If yes, did you attend? Yes No Under what name?		When did you last attend Henderson? / (Month/Year) Student ID #
List the last high school and all colleges and universities you have attended. Required: Failure to submit official required information may result in dismissal from the University.
	School Name	City		State	Dates Attended	Yr. Graduated	Degree/Hrs.Earned
H.S.
College


Are you currently eligible to return to your present college? Yes No
Have you ever received an academic or disciplinary suspension? Yes No				If so, where? and when? / /
Have you ever been convicted of or pled guilty to a felony? Yes No				If yes, please describe:
Name of: Parent Guardian Spouse				Permanent mailing address/phone: (Parent's address should be given unless you are independant of your parents.) StreetPhone CityStateZip County/Parish
Did either of your parents complete a four-year college degree? Mother Father Both Neither		If so, did either of your parents attend Henderson? Mother Father Both		How long have you lived continuously in Arkansas this current stay?
Upon entering Henderson, you plan to: Live in University housing Live off-campus			Do you expect to apply for financial aid to help meet college expenses? Yes No

State of Arkansas
Statement of Selective Service Status
In Compliance with ACT 228 of the 1997 Acts of the Arkansas General Assembly

I understand that to be eligible for admission to Henderson State University, I must register, or be exempt from registration, with the Selective Service System in accordance with the Military Selective Service Act 50 U.S.C. Appx. 451 et seq., as specified in Act 228 of the 1997 Acts of the Arkansas General Assembly. I therefore swear or affirm under penalty of perjury that I have registered with the Selective Service System, or I am exempted from such registration because of the following provision(s) of the Military Selective Services Act 228 of the 1997 Acts of the Arkansas General Assembly.

If Other, please specify:

I have read and understand all of the information on this application form and the information I have provided is factually correct and honestly prepared.

By submitting this information to Henderson State University you are agreeing to the above statement.

The campus coordinator for the Americans with Disabilities Act and Sec 504 of the Rehabilitation Act is the Executive Assistant to the President, HSU Box 7744.

It is the policy of Henderson State University not to discriminate on the basis of race, color, national or ethnic origin, sex, marital or veteran status, age or disability. Henderson works continually to assure compliance with applicable federal laws, including among other, the Civil Rights Acts; the Education Amendments, the Rehabilitation Act; the Americans With Disabilities Act, the Family Educational Rights and Privacy Act; the Student Right to Know Act; the Campus Security Act; and the Drug-Free Schools and Communities Act.