Application for Admission Please complete every item on this form that applies or required. Sign, date, and submit the application for processing. General InformationAre you a U.S. Citizen?*If No, you cannot use this form! Please contact our admissions office. Yes No Date of Application* MM DD YYYY Social Security #*xxx-xx-xxxxSeeking admission for* Fall Spring Summer Year*Full Legal Name* Mr.Mrs.Ms.Dr. Prefix First Middle Last Suffix Other Names Previously UsedMailing Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country County*Email Home PhoneCell PhoneResidency InformationU.S. Citizens*Have you been a legal resident of Arkansas for at least 6 months? Yes No Have you been a resident of Crittenden County for at least 6 months?* Yes No If Yes, since (mm/yyyy)If No, in what state and county did you reside?International StudentsWhat is your country of citizenship? Note: Resident International Students must submit an I-20.Visa typeDemographic InformationArkansas State University Mid-South is committed to equal access and employment of all qualified persons regardless of race, color, religion, sex, national origin, age, disability, DNA information, veteran status, or other unlawful factors. Inquiries regarding the non-discrimination policies should be directed to the Vice Chancellor for Student Affairs, 2000 West Broadway, West Memphis, Arkansas 72301. Telephone: (870) 733-6786. The following information does not affect the Admissions process. It is confidential and is collected for required state and federal reporting purposes only.Birthdate* MM DD YYYY Gender* Male Female Hispanic or Latino orgin?* Yes No Select all races that apply: American/Alaskan Native Asian Black/African American Hawaiian/Pacific Islander White Enrollment StatusPick OneFirst-time entering, degree-seeking A student who is entering college for the first time, and who is planning to earn a degree or certificate at ASU Mid-South (Concurrent high school students who have now graduated from high school and who are planning to earn a degree or certificate at ASU Mid-South should choose this option.) Transfer, degree-seeking A student who is transferring from another college, and who is planning to earn a degree or certificate at ASU Mid-South. College graduate, degree-seeking A student who has already earned a bachelor’s degree at another institution, and who is planning to earn a degree or certificate at ASU Mid-South. Concurrent A high school student who is taking college courses while still enrolled in high school. Transient Transferring undergraduate student not seeking a degree from ASU Mid-South but taking classes to transfer back to his/her home institution. Non-degree seeking A student who is not planning to earn a degree or certificate at ASU Mid-South (This status includes students who are taking classes for personal enrichment only.) Readmit A student who was previously enrolled at ASU Mid-South, but who has not taken classes in the last two years. Last date of attendance (mm/yyyy)College PlansIf you plan to seek a degree at ASU Mid-South, please select one. NOTE: YOU MAY ONLY SELECT ONE FROM THE FOLLOWING 3 CATEGORIES!Associate Degrees: Associate of Arts — General Education Associate of Science in Business Associate of Science in Health Studies Associate of Science in Education, Grades K-6 Associate of Science in Education, Middle Level, Grades 4-8, Language Arts & Math Associate of Science in Education, Middle Level, Grades 4-8, Language Arts & Science Associate of Science in Education, Middle Level, Grades 4-8, Language Arts & Social Studies Associate of Science in Education, Middle Level, Grades 4-8, Math & Social Studies Associate of Science in Education, Middle Level, Grades 4-8, Science & Math Associate of Science in Education, Middle Level, Grades 4-8, Science & Social Studies Associate of Science in Hospitality Management Associate of Applied Science in Aviation Maintenance Technology, Aviation Airframe Maintenance Associate of Applied Science in Aviation Maintenance Technology, Powerplant Maintenance Associate of Applied Science in Business Administration Associate of Applied Science in Digital Media Associate of Applied Science in Emergency Medical Services Associate of Applied Science in General Technology, Allied Health Associate of Applied Science in General Technology, Diesel Associate of Applied Science in General Technology, Machining Associate of Applied Science in General Technology, Mechatronics Associate of Applied Science in General Technology, Welding Associate of Applied Science in Health Studies Associate of Applied Science in Hospitality Management Associate of Applied Science in Information Systems Technology, CISCO Associate of Applied Science in Respiratory Care* Certificate of General Studies: General Studies Technical Certificates: Aviation Airframe Maintenance Technology Aviation Powerplant Maintenance Technology Business Technology Diesel Maintenance Technology Health Studies Hospitality Management Certificates of Proficiency: Advanced Emergency Medical Technician* Accounting Business CNC Operations and Programming Emergency Medical Technology (EMT)* Film and Video Production Food Service Management General Aviation Maintenance Technology Heavy Truck Diesel Maintenance Hospitality Management Machine Technology, Machinist Machine Technology, Engineering Technician Quality Technician/Metrologist Mechatronics, Level I Mechatronics, Level II Mechatronics, Level III Mechatronics, Level IV Micro-Computer Upgrade and Repair Networking (CISCO) Nursing Assistant (CNA) Phlebotomy* Process Technology I Welding Technology, Flux Core Arc Welding Technology, Gas Metal Arc Welding Technology, Gas Tungsten Arc Welding Technology, Shielded Metal Arc Welding Fabrication/Fitter *These programs require a Program Application once all pre-requisites are met.Non-Degree Seeking Yes, Non-Degree Seeking Previous Education*Select one of the following: High School Diploma General Education Development (GED) Certificate Neither HS Diploma or GED HS or GED Location* High School/GED Name City State*Year*What placement exam(s) have you taken? ACT Accuplacer Accuplacer-Next Generation ASSET COMPASS SAT Previous Colleges/UniversitiesPlease list all previous colleges/universities attended. Example - College, City, State, Years Attended, Degree Earned.College, City, State, Years Attended, Degree Earned.College, City, State, Years Attended, Degree Earned.Are you on academic or disciplinary probation or suspension from another college?* Yes No Emergency Contact Name* Mr.Mrs.Ms.Dr. Prefix First Last High school students should list parent or legal gaurdianRelationship*Phone Number* Immunization Info: Students born after 12/31/1956, must provide proof of two (2) doses of measles and rubella (MMR) immunization.Selective Service Certification:All male U.S. citizens ages eighteen (18) to twenty-six (26) must register with the Selective Service before registering for classes. This requirement does not apply to veterans and others exempt by federal law. Please check one of the following: Yes, I have registered with Selective Service No, I have not registered I am exempt The ASU Mid-South Campus Safety and Consumer Information Report is available on the college website, www.asumidsouth.edu or click here.Disability Services:The Director of the Dr. Barbara C. Baxter Learning Success Center has been designated as the College’s Coordinator of Disability Services. The office is located in the Reynolds Center on the South Campus, and can be contacted at the following email: email@example.com Student and employee complaints related to the denial or neglect of disability accommodations should be addressed to the Director of the Barbara C. Baxter Learning Success Center, the college’s compliance officer for Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act. The Director’s office is located in the Reynolds Center on the South Campus, and can be contacted at the following email: firstname.lastname@example.orgNOTICE: Students must have official high school or GED transcript, official transcripts from all previous colleges, necessary placement scores, and their immunization record on file with Arkansas State University Mid-South at the time of enrollment. Students who do not provide official transcripts and/or proof of the required immunizations will be prevented from registering for classes the next semester. The ASU Mid-South Crime Report is available on the college website, www.asumidsouth.edu.Non-discrimination Statement Arkansas State University Mid-South does not discriminate on the basis of race, color, religion, gender identity, sexual orientation, national origin, age, sex, disability, genetic information, veteran status or marital status in any of its practices, policies or procedures, and provides equal access to the Boy Scouts and other designated youth groups. This includes, but is not limited to, employment, admissions, educational services, programs or activities which it operates or financial aid. The following persons have been designated to handle inquiries regarding the non-discrimination policies: Jeremy Reece Title IX Coordinator Arkansas State University Mid-South 2000 West Broadway West Memphis, AR 72301 Phone: 870.733.6786 Email: email@example.com John Easley ADA Coordinator Arkansas State University Mid-South 2000 West Broadway West Memphis, AR 72301 Phone: 870.733.6841 Email: firstname.lastname@example.org For further information on notice of non-discrimination, visit http://wdcrobcolp01.ed.gov/CFAPPS/OCR/ contactus.cfm for the address and phone number of the office that serves our area, or call 1-800-421-3481.All applicants must read and sign the following: I certify that the information on this application is complete, accurate and true. I further certify that I understand giving false information or withholding information may make me ineligible for admission or to continue my enrollment at Arkansas State University Mid-South. Should any information change prior to enrollment, I will immediately notify the Registrar’s Office.I certify that the information on this application is complete, accurate and true.* I Agree Applicant’s Signature (Print Name)*Date* MM DD YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.