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# 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

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.


<table border=1 style='margin: auto; word-wrap: break-word;'><tr><td style='text-align: center; word-wrap: break-word;'>Name of School</td><td style='text-align: center; word-wrap: break-word;'>Address</td><td style='text-align: center; word-wrap: break-word;'>Attendance Dates</td><td style='text-align: center; word-wrap: break-word;'>Graduation Date</td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr><tr><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td><td style='text-align: center; word-wrap: break-word;'></td></tr></table>

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 _____

## FOR OFFICE USE ONLY

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.