Name:  Surname (Family/Last )    Given Name (First)   

Middle Name


Date of Birth  [None] Select a Date Delete the Date    Age     E-Mail:

Mailing Address: Street/P O Box   City/Town     State/Province   Country   
Postal Code     Telephone

Country of Citizenship  Birthplace  
Type of Visa being used or requested Country of Permanent Residence

Parents Surname     Given     
Telephone  Permanent Home Address: Street/P O Box     
City/Town     State/Province    
Country     Postal Code

Is English your native language?

Have you achieved a TOEFL score of at least 500 paper based or 173 computerized?

Have either of your parents graduated from HSU?:  


Admission Requested:

Major field of study:
Have you ever applied to HSU?  
If yes, what year?   
Did you enroll?  
   Year?  Term? 
Do you plan to obtain a degree from HSU?:



Required Test Reports:
(You must arrange for Educational Testing Services, Princeton, New Jersey, USA to send an official 
score report directly to HSU.  Institutional Code 6272. Photocopies will not be accepted as official.) 
TOEFL                                                                           SAT/ACT                                     
Date Taken: YearMonthScore Date Taken: YearMonthScore  

Test of Spoken English
Date Taken: YearMonthScore


Name and location of school:  
Date of first enrollment: 
Are you eligible to return next session?

Are you presently on suspension?   
 from any college or university?

If so, please explain in detail below:

Immigration Admission Number: 

Please list all colleges/universities, including HSU, you have attended.  Include colleges/universities at which you have officially registered even though you may not have attended classes.

Name and location:   
Dates attendedDegree  Hours earned

In case of an emergency contact: 
(name) (address)
(telephone)    Relationship to you:

How did you learn about Henderson State University? 


What influenced you to apply to Henderson State University?



Send $30.00 fee, test scores, academic records, financial statement to:

Henderson State University
Center for International Student Programs
1100 Henderson Street
HSU Box 7610
Arkadelphia, AR  71999-0001

Henderson State University is committed to the policy of providing educational opportunities to all qualified students regardless of their economic or social status, and will not discriminate on the basis of handicap, race, color, sex, creed, veteran's status, age, martial or parental status, or national origin.

Student's Full Name Date



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