admapp_4_

							                                                                       APPLICATION FOR ADMISSION
                                                                                              900 N. Portland Ave., Oklahoma City, OK 73107
                                                                                 (800) 560-4099 l (405) 947-4421 l admissions@osuokc.edu
                                                  TERM IN WHICH YOU PLAN TO ENROLL
 ________________Year                      □ Fall     □ Spring    □ Summer      □ Intersession
      STUDENT SS #              LEGAL NAME - LAST                                      FIRST                                           MIDDLE


    DATE OF BIRTH                                      OTHER NAMES                                                          EMAIL ADDRESS


 MAILING ADDRESS                              CITY             STATE          ZIP             HOME PHONE                         CELL PHONE
                                                                                              (      )            -               (    )        -
                                                                 OPTIONAL INFORMATION
 GENDER: o MALE o FEMALE
 DO YOU CONSIDER YOURSELF TO BE HISPANIC/LATINO? YES___ NO___
 SELECT ONE OR MORE OF THE FOLLOWING CATEGORIES TO DESCRIBE YOURSELF:
 o American Indian or Alaska Native o Asian o Black or African American o Native American or Pacific Islander o White
                 PLACE OF BIRTH                                                     NEXT OF KIN/EMERGENCY CONTACT
                                                       Name _____________________________________ Phone ______________________________
  City                 State   Country                 Address _____________________________________ Email _____________________________

 EDUCATIONAL OBJECTIVE                                                                             MAJOR FIELD OF STUDY
 Choose the option applicable to your current goals:
 Degree Seeking
 I plan to earn a degree at OSU-OKC. □ A.A.S. (08) □ A.S. (06) □ B.T. (01)                       See major list for proper name
 □ I plan to complete my basic coursework here and earn a bachelor’s degree at another college. (02)
 □ I plan to earn a certificate at OSU-OKC. (12)
 □ I plan to earn an Associate’s degree at another institution. (15)
 Non-degree Seeking
 □ I am taking courses for personal improvement or general interest. (11)
 □ I am taking courses to build my job skills. (14)
 How did you hear about OSU-OKC?
 □ 1 – TV           □ 2 – Radio                   □ 3 – Web Site         □ 4 – Newspaper □ 5 – Campus Recruiter
 □ 6 – High School Counselor                      □ 7 – Alumni Influence □ 8 – Friend    □ 9 – Other___________________
                                      FAMILY/HOUSEHOLD
 Number of persons in household______ Which of your parents has a four-year college degree?                               □ Mother □       Father   □   Neither

 Household Income*:            □ $0 - $22,000                     □ $22,000 - $30,500                 □ $30,500 - $38,500
                               □ $38,500 - $48,500                □ $48,500 - $57,000                 □ $57,000 +
                                                                   RESIDENCY STATUS
 How long will you have lived in the state of Oklahoma immediately preceding your enrollment at OSU-OKC?
 _________ / ___________                         Date moved to Oklahoma _________ / ___________
         Years       Months                                                          Month                 Year
 Are you active military, or dependent, assigned to Oklahoma?                   □ Yes □ No                        If yes, list home state_________________

 Are you a citizen of the United States?            □ No
                                                   □ Yes                            Do you have permanent resident status?             □ Yes        □ No
 Are you in the United States on a nonimmigrant visa?   □ Yes                       □ No
 If yes, what type of visa? ________________________________                          Country of Citizenship _______________________________
 What is your native language?       □ English □ Other ________________
 If English is not your native language, have you taken the: □ TOEFL  □ IELTS                                     If yes, date(s) taken: _________________
 (TOEFL - Test of English as a Foreign Language l IELTS - International English Language Testing System)

                                                                    OFFICE USE ONLY
 W        NW      REQ.________DEGREE____________DEPT.___________ COND.________ CMPS____________ADM REP.________

(Rev. 7/10)
OSU-OKC APPLICATION FOR ADMISSION                                                                                           page 2 of 2

                                           ACADEMIC HISTORY
Last high school attended___________________________________________________________________________
                                                                          City                                           State

High School Diploma: □ Yes – Year__________              □ No        (OR)        GED:   □Yes – Year ___________ □ No
ACT/SAT: □ Yes – Mo.______/ Year__________               □ No
List all colleges currently attending or previously attended in order of last to first. Official transcripts of all college work
attempted (whether or not credit was earned) must be submitted. If no other colleges or universities have been attended
specify “none.”

College Name                         City, State                Dates Attended Hours Earned     Degree Received
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
If additional colleges have been attended, please list on a separate sheet.             Total Hours Earned _________
My academic standing at the most-recently attended institution was: □ Good □ Probation □ Suspension

If you are enrolling in a cooperative program with an Oklahoma Technology Center, please indicate which Center:
         □ Canadian Valley                □ Eastern Oklahoma County
         □ Francis Tuttle                 □ Metro Tech
         □ Moore Norman                   □ Kiamichi
                                                 EMPLOYMENT INFORMATION*
Company Name __________________________________________________________ Work Status                        □ Full-time □ Part-time
Company Address__________________________________________________________________________________________
_________________________________________________________________________________________________________
          City                             State          Zip                      Work Phone

                                          FINANCIAL AID OR VETERANS BENEFITS
Please note: All students receiving financial aid and veterans receiving benefits are required to submit official transcripts
from all previous institutions.
Are you currently eligible for veterans benefits? □ Yes           □ No
Have you applied for and/or will you be receiving financial aid? □ Yes □ No


□   I understand that withholding requested information or giving false information may make me ineligible for admission
    to, or continuation at, OSU-Oklahoma City.

□   If I am currently enrolled in high school or college, I will furnish final, official transcript(s) within two weeks of the end
    of the semester.

□   I agree to fulfill all financial obligations which I may incur at OSU-OKC.

□   I will comply with all Board of Regents and institutional policies and procedures.

□   I will provide official transcripts, test scores and any other required documentation.

________________________________________________________________                                   __________________________
Signature                                                                                                      Date
Review this application carefully to make sure all information is complete and accurate. An incomplete application will result in a delay
in the admission/enrollment process.

*Optional Information                                                                                                 breathe easy
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