Application for Admission Southwestern Indian Polytechni

OMB Control #: 1076-0114
Expires: XX/XX/XXXX

Paperwor k Reduction A ct 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 Southwestern Indian Polytechnic Institute. 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 A ct 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 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 it may affect your eligibility for educational services.