Application for Admission Southwestern Indian Polytechni

IMB CONTROL #1076-0114
EXPIRES:

Application for Admission

SOUTHWESTERN INDIAN POLYTECHNIC INSTITUTE (SIPI)
"A National Indian Community College"
P.O. Box 10146 Albuquerque, New Mexico 87184
United States Department of the Interior
Bureau of Indian Affairs

I am applying as a:

❑ New Student
❑ Readmit Student*
❑ Extended College (SP)

Which trimester do you intend to begin taking courses?

❑ FALL

❑ SPRING

❑ SUMMER

YEAR

Legal Name (Last, First, Middle)

❑ Concurrent Student (HS)
❑ Transfer Student*
❑ Non-degree Student

Maiden Name / Previous Name

Legal or Permanent Address (Number, Street, Rt., Box, City, State, Zip Code)

Telephone No.

Commuter Address While Attending SIPI (Number, Street, Rt., Box, City, State, Zip Code)

Commuter Telephone No.

(
(

)
)

Place of Birth (City, State)

Date of Birth (Mo., Day, Yr.) You must be 18 years of age
or older to apply for the GED program

Gender (check one):
❑ MALE
❑ FEMALE

Are you a member of a U.S. Federally Recognized Tribe? If yes, provide copy of CIB with application.
❑ YES ❑ NO Name of Tribe:

Notify in Case of Emergency (Name, Address)

Relationship

Circle Highest Grade Completed in School:

Telephone No.

(

Elementary/Secondary School

College

7 8 9 10 11 12

1 2 3 4

Name and Address of Last High School Attended
If you have not graduated from high school,
have you passed a GED test? ❑ YES

U.S. Social Security No.

❑ NO

)

Remarks:
High School Graduation Date (Mo., Day, Yr.) Provide a copy
of official transcript showing graduation date

If your answer is yes, provide a GED Report of Test Results.

Are you a U.S. Veteran?
❑ YES ❑ NO If your answer is yes, please include a copy of your latest DD-214 Form with this application
*FOR TRANSFER AND READMISSION STUDENTS ONLY:
List all post-secondary schools, colleges, and universities in order of attendance. Transfer students MUST request all collegiate institutions
presently or previously attended to mail official transcript(s) of academic records directly to the Office of Admissions & Records of this college.
Applications will not be processed until all required items are received by the SIPI Admissions and Records Office.
Name of School
Address (City & State)
Dates Attended
Credits Earned

GENERAL INFORMATION -- Please answer all questions.
❑ Yes
Will you require student dormitory housing?
Do you require special services (e.g., disabilities)?
❑ Yes
If yes, state needs:
Are you currently on or pending criminal probation or parole?
If yes, explain:

❑ No
❑ No

❑ Yes ❑ No

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What is your current marital status?
❑ SINGLE
❑ MARRIED

Are you a single parent?
❑ YES
❑ NO

Do you speak your tribal language?
❑ YES ❑ NO

Are you the first generation of your family to attend a post-secondary educational institution?
❑ YES
❑ NO

Do you reside on your tribal reservation?
❑ YES ❑ NO

Select the highest level of education for each parent/guardian.
Mother's Education:

Father's Education:

❑ Completed High School Diploma or GED Equivalent
❑ Completed a Certificate (approximately 1-year training)
❑ Completed an Associate's Degree (2-year college degree)
❑ Completed a Bachelor's Degree (4-year college degree)
❑ Completed a Graduate Degree
❑ Not Applicable

❑ Completed High School Diploma or GED Equivalent
❑ Completed a Certificate (approximately 1-year training)
❑ Completed an Associate's Degree (2-year college degree)
❑ Completed a Bachelor's Degree (4-year college degree)
❑ Completed a Graduate Degree
❑ Not Applicable

ASSESSMENT SURVEY:
What is your current objective in attending SIPI? Please mark an "X" next to any or all of the statements that apply to you.

❑ Obtain an Associate Degree
❑ Obtain a Certificate
❑ Transfer to another college or university
❑ Preparation to change careers
❑ Self-improvement and/or to improve basic skills
❑ Preparation to enter the job market

❑ Meet certification/licensure requirements
❑ Personal interests
❑ Explore courses
❑ Improve skills for present job
❑ Undecided/unknown

CERTIFICATION:
This verifies that all application information I submitted to Southwestern Indian Polytechnic Institute (SIPI) is complete and true. Reporting any
false application information may be grounds for denying admission or suspension from the institution. I also agree to abide by all of the rules and
regulations of SIPI.

Applicant Signature (sign)

Social Security Number

Date

FOR PARENT/GUARDIAN OF A MINOR APPLICANT UNDER 18 YEARS OF AGE:
I am legally responsible for this applicant and hereby apply for his/her admission to SIPI. I give my consent to emergency operations, psychiatric
treatment, and dental or minor surgery, if such procedures become necessary while the student is in college. I also approve inoculations and treatment
in the field of preventive medicine as may be deemed necessary by medical personnel.

Parent/Legal Guardian Signature

Relationship

Date

(
Address (Number, Street, Rt., Box, City, State, Zip)

)

Telephone No.

SIPI/OAR/Oct. 2001

IMB CONTROL #1076-0114
EXPIRES:

Paperwork Reduction Act and Public Burden Statement:
Authority: Paperwork Reduction Act of 1995, Public Law 96-511, as amended.
This information is collected of Native American and Alaska Native individuals to determine eligibility for postsecondary education services, assist in the enrollment process, identification of students, identification of needed
health and counseling services, safety issues related to dormitory situations and for record keeping purposes. The
completed admissions forms are electronically entered into Southwestern Indian Polytechnic Institute’s Admissions
and Records system to identify and maintain current information on students, the collected data is used in
responding to the Office of Indian Education Program’s budget information requests from the Department of the
Interior, Office of Management and Budget, and Congress, the collected information is used to supply needed
information to counselors for student services and is used by health professionals to aid in the provision of health
services. The estimated burden of completing this form will take an average of 30 minutes to gather all related
information and to complete form. If you wish to make comments on the form, please send them to the Information
Collection Control Officer, Bureau of Indian Affairs, 1849 C Street NW, Mail Stop 4603 MIB, Washington, DC
20240. Note: comments, names and addresses of commenters are available for public review during
regular business hours. If you wish us to withhold this information, you must state this prominently at the
beginning of your comment. We will honor your request to the extent allowable by law. In compliance
with the Paperwork Reduction Act of 1995, as amended, the collection has been reviewed by the Office
of Management and Budget and assigned a number and expiration date. The number and expiration date
are at the top right corner of the form. Please note that an agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless there is a valid IMB clearance
number.
Privacy Act Statement:
Authority: Privacy Act of 1974, Public Law 93-579, as amended
This information collection document contains information that is covered under the Privacy Act Public Law and is
for students completing Federal records and forms that solicit personal information. The Bureau of Indian Affairs
will not disclose any record containing such information without the written consent of the respondent unless the
requestor uses the information to perform assigned duties. The primary purpose and routine uses of this information
is to determine eligibility for postsecondary educational services of the Southwestern Indian Polytechnic Institute, for
identification purposes, to render appropriate services for students and for record keeping purposes. Examples of
others who may request the information in summary are Members of Congress, or the Office of Management and
Budget for the purpose of the budget. Collection of your Social Security Number is for identification purposes and
is voluntary. Your voluntary responses are treated in a highly confidential manner.
EFFECTS OF NONDISCLOSURE: Providing this information is voluntary. If you choose not to provide
information may affect your eligibility for educational services.