Haskell Application

Admission Application
Application for Admissions
DEADLINES:

Haskell Indian Nations University

Phone: (785) 749-8454; Web Site: www.haskell.edu
Fall - June 1 Spring - November 15 Summer - April 15

_________________
_________________
What semester are you planning to attend Haskell?

o

o

Fall 20

Spring 20_ o

Summer 20

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

Last Name

Middle

First Name
Social Security Number

Maiden/Other Names

Please select which degree
you are pursuing:

O Associate of Arts (A.A.) Degree

O Bachelor of Arts (B.A.) Degree

O Associate of Science (A.S.) Degree

O Bachelor of Science (B.S.) Degree

_________________

Please write your major on
the line.

Permanent Mailing Address:
Street or P.O. Box

City

Telephone

E-Mail Address

Please select the your enrollment status:
Please select the your housing status:

0

State

0

Full-Time Student

Part-Time Student

(Enrolled in less than 12 credits)

(Enrolled in 12 or more credits)

0

Zip Code

0

On-Campus

(Must be enrolled in 12 credits)

Off-Campus
(Please list local address below.)

_________________

Street or P.O. Box

City

State

Zip Code

In case of an emergency, please provide the following information:
O

Parent

O

Spouse

O

Other:
Please write relationship.

Last Name First Name
Street or P.O. Box

City

Telephone

State

Zip Code

E-Mail Address

Applicant Demographic Information
Date of Birth:

Place of Birth

MM/DD/YYYY

City

Sex:

O

Male

O

Female

Marital Status:

State

O

Single

O

Married

O

Separated

O

Divorce

Are you currently on or pending criminal probation or parole?

o No

o

Yes

If yes, explain:

OMB Control No: 1076-0114
Expiration Date: XX/XX/XXXX

CONFIDENTIAL

Tribal Information:
Tribal Agency:

Tribal Roll Number:

_________________
Name of Tribe, Pueblo, Corporation, or Rancheria

High School Information:

City

Name of High School

Have you graduated from high school?
Have you taken the
GED:

ONo

O Yes

0

Date To

No

Date of Graduation

Anticipated Date of Graduation

Contact Information:

Office of Admission
Haskell Indian Nations University
155 Indian Ave #5031
Lawrence KS 66046-4800
www.haskell.edu

OYes
Date of
GED Exam

_________________
Ifyou have taken the GED please
submit a copy ofyour scores

Date From

State

College or University Information:

O Yes

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

Have you been awarded a degree from a University/College?

O No

o Yes

Degree/School Name

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:

Please attach the following documents:
o Verification-Tribal Enrollment (With Identification Number)
o Immunization (Showing two doses of Measles, Mumps & Rubella or MMR)
Have the following relevant documents sent to Haskell via Mail or secure digital method such as
Parchment or National Student Clearinghouse.
o Official High School Transcript

Official College(s) Transcript

(Send most current transcript if still in high school )

o Official GED Certificate with scores

Certification of Information:

I certify that the information given on this application is correct and complete and that all prior academic
work is accountedfor on this application. (Incomplete applications will not be considered.)
Student Signature

Date

OMB Control No: 1076-0114
Expiration Date: XX/XX/XXXX

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 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 15 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 0MB Control Number. Comments
concerning clarity, utility of information or burden reduction may be sent to Haskell
Indian Nations University, 155 Indian Ave, Box #5031, Lawrence, KS. 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. 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.

OMB Control No: 1076-0114
Expiration Date: XX/XX/XXXX