GRADUATE APPLICATION

PLEASE PRINT OUT THIS FORM AND FILL IT OUT
(PRINT OR TYPE)

Please remember to include your $25.00 application fee with your application form.

Social Security Number
 Mr. Ms. Other
Last Name
 First Name
MI
Permanent Address
Number & Street
Apt. #
City or Town
State
Zip Code+4 		Country
Mailing Address (If different from above)
Number & Street
Apt. #
City or Town
State
Zip Code+4 		Country
Home Phone
 Daytime Phone
E-mail Address
Birthdate

Male Female Previous Name (s)

Ethnic Origin:
White (Non-Hispanic)
Hispanic
Asian Or Pacific Islander
Black (Non-Hispanic)
American Indian or Alaskan Native
Other

Your response to this question will not affect the admission decision and is optional. This information is requested so that we may demonstrate to federal and state agencies that the institution is in compliance with appropriate regulations.
Illinois Resident? Yes No How Long?
Years Months		 County
Citizenship Status:
U.S. Citizen
Non U.S. Citizen ( Specify Country, Permanent Resident Address & Type of Visa)
Are you a veteran? Yes No Military Dates(Month/Year) from to

Applying for:
Fall (September-December) Winter (January-April) Spring (May-August)    Year

Applying as: New Student Reapplying
Degree Seeking
Undeclared
Non-Degree
1st Choice: Major Concentration

2nd Choice: Major Concentration

Have you applied to GSU before? Yes No    If Yes, Indicate term and year

Do you wish to apply for Financial Aid? Yes No
Note: Undeclared and non-degree seeking students are not eligible for financial aid.
College or universities attended. Use reverse chronological order, beginning with most recent.
Name/Campus City State Entered
Mo.Yr.		 Left
Mo.Yr.		 Degree or Hours Earned





























Unpaid account balances may be disclosed to credit reporting organizations, and you may be assessed collection, litigation, and court costs, including attorney fees incurred by the university.  Unpaid account balances will result in your being on the university hold list, which may prevent future registrations, release of transcripts, and denial of other student services.  Tuition and fees will be due and payable unless students officially withdraw during the 100% refund period as published in the Schedule of Classes or on University's website at http://www.govst.edu/catalog/acad.cal.2002_2003.html.  Failure to attend classes DOES NOT constitute official withdrawal.

This application must be signed and dated by the applicant before action can be taken. I understand that withholding information requested on this application or giving false information may make me ineligible for admission to the university or subject to dismissal. I certify that the information provided on the application if correct and complete.

Signature _________________________________________                  

Date _____________________

Governors State University is an equal opportunity institution. The university adheres to Section 504 of the Rehabilitation Act.

 

Copyright © 2004 Governors State University
Office of Admission and Student Recruitment
University Park, Illinois 60466-0975
(708) 534-5000
(708) 534-1640 (Admission's Office Fax)
gsunow@govst.edu