Haskell Application for Admission

CONFIDENTIAL OMB Control No. 1076-0114

Expires XX/XX/XX

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	○	Divorced

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

Paperwork Reduction Act and Public Burden Statement:

Authority: Paperwork Reduction Act of 1995, Public Law 96-511, as amended.

This information is collected from Native American and Alaska Native individuals seeking enrollment to Haskell Indian Nation University. The information is used to identify students, determine eligibility, and identify any health and counseling services needed, and safety issues related to dormitory situations and record keeping purposes. The completed admissions forms are electronically entered into Haskell Indian Nations University Admissions and Records system to identify and maintain current information on students. It is estimated that this form will take an average of 30 minutes to complete. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB Control Number. Comments concerning clarity, utility of information or burden reduction may be sent to Attn: Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240. Please note: comments, names, and addresses of commentators 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.

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 Education 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 Haskell Indian Nations University, 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 it may affect your eligibility for educational services.