BLINN COLLEGE APPLICATION FOR ADMISSION
                                    Texas Department of Criminal Justice                                                                    TDCJ#____________
INSTRUCTIONS: Please print or type and be sure to answer each question. Please submit this application to the campus you plan to
attend. All documents submitted to the College become part of the official files and cannot be returned.
Social Security Number:                     When do you plan to enter Blinn College? (Select only one and indicate year.)
         -        -
________________________           Fall 2008___ Spring 2009___ Summer I 2009___ Summer II 2009___ Other_________________
Which campus(es) do you plan to attend: ___Brenham ___Bryan ___Other (Identify)___________________________________
Have you previously applied at Blinn? ___YES ___NO When?__________ Previously attended? ___YES ___NO When?___________
Name: Give full legal name as it appears on all legal documents
Last_______________________________________ First______________________________ Middle_________________________
Indicate any other names under which your academic records may be -

Last_______________________________________ First______________________________ Middle_________________________
                   Permanent Mailing Address                                                              Local Mailing Address
 _________________________________________________________                            _________________________________________________________
                   Street Address or P.O. Box                                                           Street Address or P.O. Box
 _________________________________________________________                            _________________________________________________________
  City              State       Zip Code      County                                   City              State       Zip Code      County
Permanent Phone Number (_______)______________________
                                                                                         Local Phone Number (_______)___________________________
Email Address:________________________________________

Ethnic   ___1. American Caucasian (White)   ___5. American Indian/Alaskan Native   Check One:                  Sex:
Origin   ___2. American Black               ___6. International Student            ___1. U.S. Citizen          ___ Male          Date of Birth: _____/_____/_____
         ___3. American Hispanic            ___7. Other                            ___2. Naturalized Citizen   ___ Female
         ___4. Asian or Pacific Islander                                           ___3. Resident Alien
                                                                                   ___4. International         Place of Birth:

High     Name of                                    City                                         State or                                     Year	HS
School   HS                                                                                      Country                                      Graduation
Check any of the following that apply:
______ 1. Graduated from a state accredited high school.
______	 2.	 Completed	GED	-	Date	certificate	awarded	____________________.		Copy	of	official	scores	are	required.
______ 3. Dual Credit or Early Admissions, still in high school and not taking more than two college courses.
______ 4. Individual Approval. Requires approval letter from the Registrar.
______	 5.	 Non-Degree/Non-Certificate	student.		You	are	taking	course(s)	for	enrichment	only.
______	 6.	 International	Student.		Contact	Admissions	and	Records	Office	for	entrance	requirements	and	procedures.
______	 7.	 Re-entry	Student.		You	have	attended	Blinn	College	and	have	not	attended	another	college	since	leaving.
______	 8.	 Transfer	or	Co-enrolled	Student.		You	are	transferring	to	Blinn	College	or	you	are	attending	another	university/college	during	
            the same semester.
______		9.	 Home	School	Graduate.		You	have	graduated	from	a	certified	home	school	program.	
                      Is this your first time in college? ___YES ___NO If yes, go to the THEA Section.
List ALL colleges or universities you have attended including Blinn College. List most recent first. Failure to disclose colleges may
result in non-admission. If you have attended a college or university, a transcript from each institution attended will be required.
           College or University Name                                              Location                              First Semester/Year        Last Semester/Year

Total semester hours completed at all colleges/universities: ___ 0 to 29 hours ___ 30 to 71 hours ___ 72 hours and up.
Are you presently on disciplinary suspension/probation? ___YES ___NO		If	Yes,	specify______________________________________
THEA Status: ___I have taken the THEA Test. ___I am exempt from the THEA Test. ___I have not taken THEA Test.
Official	THEA	scores	or	proof	of	exemption	must	be	provided	prior	to	admissions.
Completion of this application serves as authorization to access your scores. Upon request, the college will provide the student a copy
of the scores. The student has the right to challenge the scores if he/she believes they are not correct.
What	is	your	intended	major?________________________		Do	you	plan	to	earn	a	degree	or	certificate	in	this	major?	___YES ___NO
Are	you	planning	to	seek	a	teaching	certificate	in	addition	to	your	degree?			___YES ___NO
Emergency contact person (optional):          Relationship to you: ( ) Parent           ( ) Spouse        ( ) Other
     Name: __________________________________                  Address___________________________________________
     Home phone: (           )______________________           City ______________________________________________
     Day phone: (         )_______________________             State_________________________ Zip_________________
Have you been involved in any of the following while in high school? (Check any of the following that apply)
	    Limited	English	Proficiency	Class____			Future	Teacher	Club	or	Class____
     Honors Program____ Tech-Prep Program____ Agricultural Science____ 4H/FFA____
Please indicate the highest level of your parents’ or court appointed legal guardian’s educational background:
     Father/Legal Guardian: Not a high school graduate____ High School diploma or GED____
                           Some College____ Associate Degree____ Bachelor’s Degree____ Graduate/Professional Degree____
     Mother/Legal Guardian: Not a high school graduate____ High School diploma or GED____
                           Some College____ Associate Degree____ Bachelor’s Degree____ Graduate/Professional Degree____
PART I. Certification of Residency. All students must complete this section.
I	understand	that	officials	of	my	college/university	will	use	the	information	submitted	on	this	form	to	determine	my	status	for	residence	
eligibility. I authorize the college/university to verify the information I have provided. I certify that the information on this application is
complete and correct and I understand that the submission of false information is grounds for rejection of my application, withdrawal of
any offer of acceptance, cancellation of enrollment, and/or appropriate disciplinary action.

Signature: __________________________________________________ Date: ______________________________

Blinn College seeks to provide equal education without regard to race, color, creed, religion, sex, disabling condition, age, national origin,
or veteran’s status. This policy extends to all programs and activities supported by the college.

     This information is being provided to all new college students in the state of Texas. Bacterial Meningitis is a serious, potentially
deadly	disease	that	can	progress	extremely	fast	-	so	take	utmost	caution.		It	is	an	inflammation	of	the	membranes	that	surround	the	brain	
and spinal cord. The bacteria that causes meningitis can also infect the blood. This disease strikes about 3,000 Americans each year,
including 100-125 on college campuses, leading to 5-15 deaths among college students every year. There is a treatment, but those who
survive may develop severe health problems and disabilities.
What are the Symptoms:
      High fever                           Severe headaches
      Rash or purple patches on skin       Vomiting
      Light sensitivity                    Stiff neck
      Confusion and sleepiness             Nausea
      Lethargy                             Seizures
     There may be a rash of tiny, red-purple spots caused by bleeding under the skin. These can occur anywhere on the body. The more
symptoms, the higher the risk, so when these symptoms appear seek immediate medical attention.
How is Bacterial Meningitis Diagnosed?
      • Diagnosis is made by a medical provider and is usually based on a combination of clinical symptoms and laboratory results from
         spinal	fluid	and	blood	tests.		
      • Early diagnosis and treatment can greatly improve the likelihood of recovery.
How is the Disease Transmitted?
     The disease is transmitted when people exchange saliva (such as kissing, or by sharing drinking containers, utensils, cigarettes,
toothbrushes, etc.) or come in contact with respiratory or throat secretions.
How Do You Increase Your Risk of Getting Bacterial Meningitis?
      • Exposure to saliva by sharing cigarettes, water bottles, eating utensils, food, kissing, etc.
      • Living in close conditions (such as sharing a room/suite in a dorm or group home).
What are the Possible Consequences of the Disease?
     • Death (in 8 to 24 hours from perfectly well to dead)
     • Permanent brain damage
     • Kidney failure
     • Learning disability
     • Hearing loss, blindness
     •	 Limb	damage	(fingers,	toes,	arms,	legs)	that	requires	amputation
     • Gangrene
     • Coma
     • Convulsions
 Can the Disease be Treated?
     • Antibiotic treatment, if received early, can save lives and chances of recovery are increased. However, permanent disability or
         death can still occur.
     • Vaccinations are available and should be considered for:
     • Those living in close quarters
     • College students 25 years old or younger
     • Vaccinations are effective against 4 of the 5 most common bacterial types that cause 70% of the disease in the U.S. (but does
         not protect against all types of meningitis).
     • Vaccinations take 7-10 days to become effective, with protection lasting 3-5 years.
     • The cost of vaccine varies, so check with your health care provider.
     • Vaccination is very safe - most common side effects are redness and minor pain at injection site for up to two days.
How Can I Find Out More Information?
     • Contact your own health care provider.
     • Contact web sites:;

I acknowledge that Blinn College has provided me with and I have read and understand this information.

________________________________________________                            ________________________________________________
Signature                                                                   Social Security Number or Student ID Number

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