KENTUCKY STATE UNIVERSITY OFFICE OF THE REGISTRAR PHONE: 502-597-6234 FAX 502-597-6239

RE-ENROLLING STUDENT APPLICATION

Social Security Number: ___ Last KSU Enrollment: ___ Term Year

Social Security Number
Last KSU Enrollment
Year
undefined
Year
Spring
Fall
Summer

Name: ___ ___ ___ Last First MI Maiden/Previous

Name
First
MI
Maiden/Previous

Permanent Address: ___

Permanent Address

City: _____ State: _____ Zip Code: _____ Phone: _____

City
State
Zip Code
Phone

Local Address: ___

Local Address

(If Different)

City: _____ State: _____ Zip Code: _____ Phone: _____

City
State
Zip Code
Phone

Email Address: ___ Birthdate: ___

Email Address
Birthdate

Marital Status: ☐ Married ☐ Single ☐ Other Sex: ☐ Male ☐ Female ☐

Single
undefined
Male
Other
Married
Female

Ethnic Origin: □ Black □ White □ Hispanic □ Asian/Pacific Islander □ American Indian □ Other

Black
White
Hispanic
Asian/Pacific Islander
American Indian
Other

U.S. Citizen: ☐ Yes ☐ No Veteran: ☐ Yes ☐ No

U.S. Citizen
U.S. Citizen
U.S. Citizen
U.S. Citizen

List all places of residence for the 18 month period prior to the date of this application. Give cities, states and dates. City and State ___ Dates ___ ___ ___

City and State [1]
Dates [1]
City and State [2]
Dates [2]
City and State [3]
Dates [3]

List all high schools, colleges/universities you have attended since your last KSU enrollment.

Name of School Address Attendance Dates Graduation Date

Name of School [1]
Address [1]
Attendance Dates [1]
Graduation Date [1]
Name of School [2]
Address [2]
Attendance Dates [2]
Graduation Date [2]
Name of School [3]
Address [3]
Attendance Dates [3]
Graduation Date [3]

Prior to finalizing your enrollment, the Office of the Registrar must receive official transcripts from the above institutions.

I affirm that all information supplied in this application is true and complete. I understand that withholding information and/or providing false information will make my enrollment subject to cancellation.

Signature _____ Date _____

Signature
Date

FOR OFFICE USE ONLY

Date Received: ___ By: ___ Residency: ___

Date Received
By
Residency

Academic Major: ___ Level: ___ Degree: ___

Academic Major
Level
Degree

It is the policy of Kentucky State University not to discriminate against any individual in any of its educational programs, activities, or employment on the basis of race, color, national origin, sex, disability, veteran status, age, religion, or marital status.