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Application for Undergraduate Admission


									Application for
Undergraduate Admission                                                                                                                              1401 South U.S. Hwy. 421
Instructions for applying to Purdue North Central                                                                                                    Westville, IN 46391-9542
• Type or print clearly your full, legal name in ink                                                                                                 1-219-785-5505
• Students transferring from another university must submit a $30 transcript evaluation fee.                                                         1-800-872-1231(in-state)
• Missing or incorrect items will delay processing of your application                                                                               AIM: pncadmissions4
• If you have been academically dismissed from any Purdue campus contact PNC Enrollment Services                                                     email:
  for readmissions instructions and deadlines.                                                                                             
• You may apply online at                                                                                      an equal access/equal opportunity university

      No Previous College Work                                                                         Some Previous College Work

         First-time Freshman - If you have                                   Transfer - If you have attended college,                 Permanent Regional Campus
         never attended a college, submit this                               but never attended PNC or another                        Transfer from Purdue - If you are
         application and an official high-school                             Purdue campus, submit this application,                  currently attending another Purdue
         transcript or GED scores. If you gradu-                             an official high school transcript or GED                campus and want to transfer perma-
         ated from high school less than three                               scores and official transcripts from                     nently to PNC, submit this application.
         year ago, submit SAT I or ACT scores.                               all colleges you have attended. If you
                                                                             hold a bachelor's degree, you do not                     Temporary Regional Campus
         Non-Degree - If you are planning to                                 need to submit a high school transcript.                 Transfer from Purdue - If you are
         take a few courses for credit, but do not                           There is a one time $30 transcript evalua-               currently attending another Purdue
         intend to pursue a degree, submit this                              tion fee on transcripts outside of the                   campus and want to take classes
         application. Non-degree students may                                Purdue system.                                           temporarily at PNC, submit this
         apply no more than 18 semester hours                                                                                         application.
         of work towards an undergraduate                                    Re-entry - If you previously attended
         degree at a Purdue campus. Non-                                     PNC or another Purdue campus as a                        Non-Degree With College Course
         degree students are not eligible for                                regularly admitted student, submit this                  Work or "Guest" - If you are planning
         financial aid.                                                      application and official transcripts from                to take a few courses for credit, but do
                                                                             any colleges attended since your last                    not intend to pursue a degree, submit
                                                                             enrollment at Purdue.                                    this application. You may enroll tem-
                                                                                                                                      porarily at PNC for up to 18 credit hours.

Students with Disabilities – Purdue University North Central is
                                                                       Why We Want To Know
committed to providing equal access and equal opportunity to
University courses, activities and programs for students with          Although reporting your Social Security Number (SSN) to Purdue North Central is not required and your SSN
disabilities. Students with documented disabilities that sub-          will not be used as your Purdue student identification number, it is required to receive certain federal tax ben-
stantially limit a major life activity, such as learning, walking or   efits. Additionally, the SSN is helpful to accurately match your application with other records such as SAT or ACT
seeing, may qualify for academic adjustments and/or services.
                                                                       scores. Disclosure of your SSN will be restricted to university business processes, such as those required for fed-
To request information about academic adjustments, auxiliary
aids, or services, please contact the Disability Services Coordina-    eral and state reporting as well as institutional purposes. By providing your SSN, you authorize the university
tor at (219) 785-5374. Relay Indiana is used for TDD Communi-          to disclose it to third parties as necessary for these purposes.
cations 800-743-3333.
                                                                       Purdue University is committed to assisting all members of the campus community in providing for their own
Purdue University North Central is an equal access/equal
opportunity university. No qualified person will be denied             safety and security. The University prepares an Annual Security Report containing statistics and information re-
admission or employment, nor will any student or employee be           lating to campus safety and security policies and programs. All admitted students will receive Purdue Univer-
subjected to discriminatory treatment or be excluded from              sity North Central Annual Security Report Notice. The report is available at, If you
participation in any educational program or activity on the basis      would like a paper copy of the Report, please call 219-785-5220.
of race, religion, color, sex, age, national origin, disability, or
status as a disabled Vietnam era veteran.

revised 1/12                                                                                                                                                                                        1
                                                    PURDUE NORTH CENTRAL DEGREES

    MASTER’S DEGREES                                         Early Childhood Education (LA)                           Secondary Education (LA)
    (Requires Graduate Application)                          Electrical Engineering (ET)                                Subject tracks in:
    Business Administration                                  Elementary Education (LA)                                  Life Sciences
    Elementary Education *                                   Engineering Technology (ET)                                Math
                                                                Concentrations in:                                      Physical Science
    BACHELOR’S DEGREES                                          Electrical & Computer Engineering                     Social Work (LA)
    Behavioral Science (LA)                                       Technology
       Psychology                                               Industrial Engineering Technology                     ASSOCIATE DEGREES
       Sociology                                                Interdisciplinary Engineering Technology              Building Construction Management (ET)
    Biology (S)                                              English (LA)                                             Computer & Information Technology (ET)
       Concentrations in:                                    Human Resources (B)                                      Electrical & Computer Engineering (ET)
       Ecology                                               Liberal Studies (LA)                                     Mechanical Engineering Technology (ET)
       Microbiology                                             Concentrations include, but are not limited           Organizational Leadership & Supervision (B)
       Pre-Dentistry                                            to the following:                                        Emphasis in Human Resources
       Pre-Medicine                                             Behavioral Science                                    Organizational Leadership & Supervision (B)
       Pre-Veterinary Medicine                                  Business
    Business (B)                                                Communications                                        CERTIFICATES
       Concentrations in:                                       Math Statistics                                       Computer & Information Technology (ET)
       Accounting                                               Natural Science                                       Human Resources (B)
       Economics                                                Organizational Leadership & Supervision               Mechanical Engineering Technology (ET)
       Management                                            Mechanical Engineering (ET)                              Office Productivity (ET)
       Marketing                                             Mechanical Engineering Technology (ET)                   Organizational Leadership & Supervision (B)
    Communication (LA)                                       Nursing (S)                                              Process Improvement (ET)
    Computer & Information Technology (ET)                      Nursing - BS                                          Professional Communication (LA)
    Construction Engineering and                                Nursing 2+2 to BS Degree Completion                   Quality Control (ET)
       Management Technology (ET)                            Organizational Leadership & Supervision (B)              Supervision (online) (B)

    * A graduate degree in Education offered by West Lafayette on the Purdue North Central Campus.

                                                                 TRANSFER PROGRAMS

      A student can begin any of the programs below at Purdue North Central. After 1, 2 or 3 years, the student can apply for transfer to complete the degree at another
                    Purdue campus or another college or university. This is a partial listing of majors/programs. See for complete listings.

    Aeronautical and Astronautical Engineering               Dietetics                                                Landscape Architecture
    Agribusiness Management                                  Entomology                                               Mathematics Education
    Agricultural and Biological Engineering                  Farm Management                                          Mathematics/Computer Science
    Animal Agribusiness                                      Financial Counseling and Planning                        Movement and Sport Science
    Animal Production                                        Fine Arts                                                Natural Resources
    Apparel Design and Technology                            Fisheries and Aquatic Sciences                           Nuclear Engineering
    Applied Mathematics                                      Food Science                                             Nutrition, Fitness, and Health
    Art Education                                            Foods and Nutrition in Business                          Occupational Health Science
    Art History                                              Forestry                                                 Personal Fitness Training
    Athletic Training                                        Health and Safety Education                              Physical Education
    Aviation Technology                                      Health Promotion                                         Radiologic Health Science
    Biological and Food Process Engineering                  Horticultural Science                                    Selling and Sales Management
    Biomedical Engineering                                   Hospitality and Tourism Management                       Turf Science
    Chemical Engineering                                     Interdisciplinary Science                                Wildlife
    Chemistry                                                International Agronomy                                   Wood Products Manufacturing Technology

Application for Undergraduate Admission
Missing or incorrect information will delay consideration of your application. Please print clearly.

_____________________________________________________________ ____________________________
Last Name                                          First                     Middle                Maiden (or other former name)                   Official Use Only

________/________/_________                __________________________________ ___________                                                          PU ID#         ___________________
Birth Date (Mo/Day/Yr)                                  Social Security Number                            Gender
                                                                                                                                                   Date Rec’d     ___________________
                                                                                                                                                   Eval Fee       ___________________
Street Address                                          City                                     State                      Zip
                                                                                                                                                   Check          ___________________
(_______) ___________________________________                           ___________________________________________
Home Phone                                                                               County (if an Indiana Resident)                           Proc Int       ___________________

(_______) ___________________________________                          ____________________________________________
Cell Phone                                                                                                    Student’s Email

1. Ethnicity:    Hispanic or Latino         Non-Hispanic or Non-Latino
   Race:      American Indian/Alaskan Native         Asian       Black or African American
      Native Hawaiian or other Pacific Islander      White
    (Check the appropriate boxes. State and federal laws pertaining to civil rights require the university to report ethnic data.)

2. Your place of employment _______________________________________________________________                                                                     Full-time          Part-time

3. If out of school for more than 12 months, describe your activities since your last enrollment (employment, homemaking, military service, etc.)

4. Country of citizenship:                  United States                Other (specify country) _____________________________________________________

5. If non-U.S. citizen:               Permanent Resident Number __________________________ (Attach a copy of Green Card or I-94 form)

         International            Asylee or Refugee               None of the Above              By selecting “None of the Above” as my citizenship type, I understand
                                                                                                 that I am not eligible for Indiana resident tuition.

6. Residence: Which state (or foreign country) do you claim as your legal residence? ____________________ _______________________
                                                                                                                                     State                             Foreign Country
    Dates you have lived in Indiana:                   Birth to present             Indiana resident (m/y) ________ to (m/y) ________                           Never resided in Indiana

7. Parent or Guardian (if under 21) ___________________________________________________________
                                                                      Last                            First                       Middle

    _____________________________________________________________________________                                                            (______)______________________
    Number/Street                                          City                          State                            Zip                                    Parent Phone

8. Have either of your parents earned a four-year college degree?                                             yes        no
    For research purposes only

9. Are you a veteran?                    Yes, (attach photocopy of DD 214 )                      No

10. Alumni Affiliation: Check any that have attended or are attending Purdue University.                                          Father     Mother             Brother            Sister

11. If admitted, when will you begin at PNC?                           Fall (August)             Spring (January)                 Summer I (May)         Summer II (June) Year 20___

12. Have you attended another Purdue Campus?                                  Yes          No         If yes, specify last campus attended ___________________________

13. Intended major _______________________________________________________________________________________________

                                                               Admissions Office
                    (219) 785-5455 • (219) 872-0527 • (219) 462-4197 • (800) 872-1231 (in-state) • Relay Indiana (800) 743-3333

    14. High school information _______________________________________________________________________________________
                                                                              Name                                                        City                               State

        Year of graduation ________________ GED completion date (if applicable)                                  _______________________

        Indicate all date(s) you took or will take the SAT and/or ACT ___________________                                       ____________________ ___________________
                                                                                                  SAT (month/year)                       ACT (month/year)                         Neither

    15. Are you on academic probation with any university/college?                              yes      no Have you been dropped from any university/college?                              yes        no

    16. List all colleges/universities you have attended. See cover page for transcripts required for your admission status. Place an asterisk (*)
        next to any institution in which you are currently enrolled. Failure to provide official transcripts will disqualify your application.
        Transcripts for another Purdue Campus do not need to be submitted.
        _____________________________ _____________________ _____________ _____________ ____________________________
        Name of college/university                                            City and State               From (Month/Year) to          (Month/Year)       Degree and year received (if applicable)

        _____________________________ _____________________ _____________ _____________ ____________________________
        Name of college/university                                            City and State               From (Month/Year) to          (Month/Year)       Degree and year received (if applicable)

        _____________________________ _____________________ _____________ _____________ ____________________________
        Name of college/university                                            City and State               From (Month/Year) to          (Month/Year)       Degree and year received (if applicable)

    17. My intention is to (check all that apply)     Be a full-time student       Complete my degree at PNC
            Complete my degree at another Purdue campus               Complete my degree outside the Purdue system
            Be a part-time student         Take 1 or more courses, but do not plan to earn a degree
    18. If Non-Degree my intention is to (check all that apply)         Pursue a degree program at PNC         Take one or two courses at PNC
            Pursue a certificate at PNC           Renew teaching license        Attend courses for teacher certification only
    19. I certify that all the information provided is accurate and true. I understand that falsified information may result in denial of admission and/or termination of
        enrollment at Purdue University North Central. I affirm, under the penalties for perjury, that the following representations, including information related to my
        citizenship status and/or presence in the United States, are true. I authorize Purdue University North Central to report my admission status and academic program
        to my high school counselor for the purpose of curriculum development and improvement of instruction. I authorize secondary and post-secondary schools I have
        attended to release information needed by Purdue University North Central to process and verify my application. I authorize Purdue University North Central's
        Division of Financial Aid to release, as it deems appropriate, information on my academic program (including grades) and the amount of any financial award I may
        receive to agencies, institutions, and others involved in providing funds for my education. I agree to abide by the policies, rules and regulations of PNC.

        _____________________________________________________ ___________
                                          Signature of Applicant                                                 Date
        A complete application will ensure the processing of your application as quickly as possible. All records submitted become the property of Purdue University.

                           For current high school students only (to be completed by the high school guidance counselor)
        Please complete the information below and append any information that might help PNC make an informed admission decision. Attach an official copy of
        the applicant’s H.S. transcript, including courses in progress and SAT or ACT scores and mail to: PNC Admissions, 1401 S. U.S. Hwy. 421, Westville, IN 46391

        Student Name ______________________________________________________________
        Accreditation: High School is            accredited           not accredited by a state educational agency
        Rank in Class ______/______ after                 six         seven          eight semesters          school does not rank students           G.P.A. _______ Scale _______
        Test scores           SAT:       Date _________                        CR _____________                          M _____________                           W _____________
                              ACT:       Date _________                        E _____________                           M _____________                           R _____________
                                                                               SR _____________                          C _____________                           EW ____________

        Indiana residents only                 Applicant: Pursuing CORE 40 Diploma      yes                    no Passed GQE/ISTEP       yes      no Passed ECA                         yes       no
        Please do not leave blank                         Pursuing Academic Honors Diploma                     yes    no      Twenty-first Century Scholar   yes                         no
        Senior year course in progress: (if school is on a block schedule, please list courses in all blocks for senior year)
                       Seventh Semester (Block 1/Block 2)                                                          Eighth Semester (Block 3/Block 4)
        ______________________________________________                                                          ______________________________________________
        ______________________________________________                                                          ______________________________________________
        ______________________________________________                                                          ______________________________________________
        ______________________________________________                                                          ______________________________________________
        ______________________________________________                                                          ______________________________________________
        ______________________________________________                                                          ______________________________________________
        ______________________________________________                                                          ______________________________________________

        Comments _____________________________________________________________________________________________________________________________

        ____________________________________________                                       ___________________________________________                                    ____________
          Counselor’s Signature                                                                                   Counselor’s Name (Please Print)                                    Date
        ____________________________________________                                       ____ ____ ____ ____ ____ ____                           (____) _____________________
4         High School                                                                       CEEB Code Number                                          Guidance office phone number

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