Which campus will you be attending? (Please click on one)

Lorman Campus Natchez Campus

Please Type in ALL Information

Today's Date (ex. 01-01-1997)

Social Security Number (ex. 999-99-9999)

Name: Last First MI
Maiden or other names used:

MAILING ADDRESS:

Box, Rte., or Street

City State Zip

County, if in Mississippi

Country, if not U.S.

Work Phone # {ex. (111) 222-3333}

Home Phone # {ex. (111) 222-3333}

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ALCORN STATE UNIVERSITY complies with all laws regarding affirmative action and equal opportunity in all its activities and programs and does not discriminate against anyone on the basis of age, creed, color, national origin, race, religion, sex, handicap or military status. The following information is requested so the university can satisfy reporting requirements to the U. S. Department of Education.

GENDER: Male Female

Ethnic Background (Select One)

Black Non-Hispanic Indian or Alaskan Native Asian or Pacific Islander

Hispanic White Non-Hispanic Other

Are you a U.S. Citizen? Yes No If no, what country?

Date of Birth {ex. 01-01-1997}      City of Birth State of Birth

Marital Status: Married Single Widowed Divorced    

Church Preference: Baptist Catholic Church of Christ Disciples of Christ Episcopal Lutheran Methodist Presbyterian Other         If other, please specify

Do you have any health problems or physical handicap? Yes No

If yes, please describe

College Father Attended           Date Father Attended That College{ex. 01/96-01/97}

College Mother Attended           Date Mother Attended That College{ex. 01/96-01/97}

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High School Student Attended Year of Graduation

High School Address

High School City State Zip

If General Education Development (GED), give date and year

Have you taken the ACT? Yes No Date Score

Have you taken the SAT? Yes No Date Score

Have you requested that the scores be sent to Alcorn State University? Yes No

Colleges or Universities attended since high school: 1. Name of University City/State Date Attended {ex. 01/96-01/97} 2. Name of University City/State Date Attended {ex. 01/96-01/97} 3. Name of University City/State Date Attended {ex. 01/96-01/97} Do you have a degree? N/A Yes No If yes, Type Major Do you plan to use these credits at Alcorn State University? N/A Yes No Are you eligible to re-enter the last college or university you attended? No Yes

How do you plan to attend: (click on one)

Full-Time or Part-Time

In What Field Do You Plan to Major: (choose only one)

21 Accounting	22 Health Systems Management
27 Admin. Office Management	19 History
43 Agribusiness Management	19A Social Science Education
44 Agricultural Economics	38 Industrial Technology
46 Animal Science	14 Mathematics
11 Biology	14A Mathematics - Teaching
11A Biology - Teaching	15 Bachelor of Music Education
01 Biology Medical Technology (Cooperative Program)	39 Bachelor of Music
61 Biology Physical Therapy	62 Nursing (A.S. Degree)
23 Business Administration	63 Nursing (B.S. Degree)
12 Chemistry	37 Nutrition and Dietetics
12A Chemistry - Teaching	47 Plant And Soil Science
31 Child Development	10 Political Science
52 Communications (Print, Broadcast)	48 Pre-Engineering
08 Computer Science	05 Pre-Nursing
51 Criminal Justice	30 Psychology
18 Economics	50 Recreation
24 Elementary Education	17 Sociology/Social Work
13 English	28 Special Education
13A English - Teaching	40 Applied Science Education
32 General Agriculture	40A Agricultural Education
41 General Studies (Non-Traditional/Adult Students)	40B Business Education
25 Health & Physical Education	40C Family and Consumer Sciences
29 Health Science	40D Technology Education

Year Applying for               Which term? (select one) Spring Summer I Summer II Fall

I am applying as:  (click on one) Freshman          Transfer          Special (non-degree)          Returning Student

Have you been immunized for German Measles (Rubella)? Yes No

Have you been immunized for Red Measles (Rubeola)? Yes No

Have you been immunized for Mumps? Yes No

(If you answered "no" to any of the above, you must be immunized prior to enrolling at Alcorn. If you answered "yes", your immunization must have taken place after 1968. The first dose must have been given on or after the first birthday and the second dose at least one month or more thereafter.)

INTERNATIONAL STUDENTS: Have you been screened for Tuberculosis by chest X-Ray? N/A Yes No (Chest x-ray must be three months prior to enrolling at Alcorn.)

PROSPECTIVE NURSING STUDENTS ONLY: Have you attended Nursing School? N/A Yes No If yes, where If yes, when {ex. 01/96-01/97} Reason for leaving Are you a Licensed Practical Nurse? N/A Yes No If yes, do you plan to take the Challenge Examination for Nursing Fundamental Skill Course (ASN)? N/A Yes No Have you completed College Algebra? N/A Yes No Where? When? Grade Have you completed Anatomy & Physiology I? N/A Yes No Where? When?Grade Can you provide proof of Hepatitis B vaccination? N/A Yes No (If yes, submit proof. If no, you must receive vaccination and provide proof or submit an official declination statement.)

EMERGENCY CONTACT: Name Relationship Address: Daytime phone {ex. (111) 222-3333}: Do you have any physical or mental limitations that will prevent you from actively participating in all aspects of the program of study in Nursing? No Yes