Haskell Application for Admission

CONFIDENTIAL OMB Control No. 1076-0114

Expires 12/31/08

NEW/TRANSFER

Haskell Indian Nations University

Application for Admissions Phone: (785) 749-8454; Web Site: www.haskell.edu

DEADLINES:

Fall – June 30

Spring – November 15

Summer – April 15

What semester are you planning to attend Haskell?

○

Fall 20__

○

Spring 20__

○

Summer 20__

Legal Name: (as appears on legal documents, i.e. birth certificates, court documents)

Last Name First Name Middle

		- -
Maiden/Other Names		Social Security Number

Please select which degree you are pursuing:	○	Associate of Arts (A.A.) Degree	○	Bachelor of Arts (B.A.) Degree
	○	Associate of Science (A.S.) Degree	○	Bachelor of Science (B.S.) Degree
Please write your major on the line.

Permanent Mailing Address:
Street or P.O. Box		City State Zip Code

( )
Telephone		E-Mail Address

Please select the your enrollment status:	○	Full-Time Student	○	Part-Time Student
	(Enrolled in 12 or more credits)			(Enrolled in less than 12 credits)

Please select the your housing status:

○

On-Campus

○

Off-Campus

(Must be enrolled in 12 credits) (Please list local address below.)

Street or P.O. Box		City State Zip Code

In case of an emergency, please provide the following information:
	○	Parent	○	Spouse	○	Other:
Last Name First Name							Please write relationship.
Street or P.O. Box					City State Zip Code

( )
Telephone		E-Mail Address

Demographic Information

Date of Birth:		Place of Birth
/ /
MM/DD/YYYY		City State

Gender:	○	Male		Marital Status:	○	Single	○	Married
	○	Female			○	Separated	○	Divorce

Are you currently on or pending criminal probation or parole?

○

No

○

Yes

If yes, explain:

Tribal Information:
Tribal Agency:		Degree of Blood or Tribal Roll Number:
Name of Tribe, Pueblo, Corporation, or Rancheria

High School Information:
Name of High School		City State		Date From		Date To

Have you graduated from high school?	○	Yes		○	No
			Date of Graduation			Anticipated Date of Graduation

Have you taken the GED:	○No	○Yes			Have you taken the ACT/SAT: (Required)	○No	○Yes
If you have taken the GED please submit a copy of your scores				Date of GED Exam	If you have taken the ACT/SAT, please have your official scores sent to Haskell Indian Nations			Date of ACT/SAT Exam
School Code - 010438; ACT Haskell Code – 1415; SAT Haskell Code - 0919
College or University Information:

Have you ever attended a class at another college or university? ○ No ○ Yes

Have you been awarded an associates degree or will be completing a degree? ○ No ○ Yes

Name of College or University		City State		Month/Year		Month/Year
Name of College or University		City State		Month/Year		Month/Year
Miscellaneous Information:
List any activities in which you would like to participate

Certification of Information:
I certify that the information given on this application is correct and complete and that all prior academic work is accounted for on this application. (Incomplete applications will not be considered.)
Student Signature		Date

Please mail the following that apply to you and mail your documents to the address below:

○ Completed Application

○ $10.00 Money Order

○ High School Transcript

○ Official ACT/SAT scores

○ Copy of GED score (if applicable)

○ Official College(s) Transcript

○ Immunization (MMR1 & 2)

○ Copy of Tribal Enrollment Card

○ Essay

Mailing Address:

Office of Admission

Haskell Indian Nations University

155 Indian Ave #5031

Lawrence KS 66046-4800