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

Re-enrolling Term: □ Fall □ Spring □ Summer ___ Year ___ Major

Name: ___ ___ ___ Last First MI Maiden/Previous

Permanent Address: ___

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

Local Address: ___

(If Different)

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

Email Address: ___ Birthdate: ___

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

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

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

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 ___ ___ ___

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

Name of School Address Attendance Dates Graduation Date

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 _____

Date Received: ___ By: ___ Residency: ___

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.