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APPLICATION FOR ADMISSION -- 006 MARTINSBURG CENTER

1. Name and Address


Student Name  
Last Name:
First Name:
Middle Name:
Suffix:
   
Have you ever been enrolled in school under any other name(s)? Yes   No
Last Name:
First Name:
Middle Name:
   
Last Name:
First Name:
Middle Name:
   
Permanent Address  
Street:
City:
County:
State:
Zip Code:
Country:
International Postal Code:
   
Mailing Address (if different)  
Street:
City:
County:
State:
Zip Code:
Country:
International Postal Code:
   
   
Contact Information  
Home Telephone:
Cell Phone Number:
Primary E-mail Address:
Alternate/Work E-mail Address:

2. Personal Information


Applicant Information  
Gender: Male   Female
   
Are you Hispanic/Latino? Yes   No
   
Please check one or more: American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White  
   
With what race or ethnicity do you most closely identify with? American Indian or Alaskan Native
Asian or Pacific Islander
Black (not of Hispanic origin)
Hispanic
White (not of Hispanic origin)
   
Have you served or are you currently serving in the U.S. Armed Services? Yes   No
   
These questions are strictly optional and will in now way affect the decision of whether to admit any applicant. Shepherd University requests that these questions be completed to assist the college in complying with its obligations under state and federal law to attempt to collect this data and to periodically report the statistical totals in various reports, including the annual EEO/AA Plan published by the Affirmative Action Officer.
   
   
Citizenship Information  
Are you a citizen of the United States? Yes   No
If not, what type of visa immigration status do you hold?
Visa or permanent resident number:
Miscellaneous Information  
Have you been convicted of any offense other than a misdemeanor or minor traffic violation? Yes   No
If yes, please explain:
Emergency Contact Information  
   
First Name:
Middle Name:
Last Name:
Relationship:
Street:
City:
U.S. State/Territory:
Zip Code:
Country:
   

3. Enrollment Information


Enrollment Information  
I wish to apply for: Summer 2014   Fall 2014   Spring 2015
   
Please check all that apply: Freshman
Early Admissions
Honors Program
Readmit (Semester and year last enrolled )
Transfer
Transient
   
Do you already hold a baccalaureate degree? Yes   No
   
Intended Major: Regents Bachelor of Arts
Registered Nurse to Bachelor of Science in Nursing
Bachelor of Arts in Early Education
   
Additional Information  
If a West Virginia resident, how long have you (and/or your parent or guardian) lived in West Virginia?
Academic Information  
   
High School:
City:
U.S. State/Country:
Date of Graduation:
Did you receive a GED? Yes   No
If yes, location and date.
   

4. College Information


College Information

All transfer applicants--including high school students who have taken college classes--must complete this section. Transfer students must have two (2) official transcripts sent to the Office of Admissions from each college previously attended. Incomplete information may result in disciplinary action or denial of admission.

Have you been or are you presently enrolled in any college or university? Yes   No

List all colleges you have attended and the hours/degrees earned, beginning with the most recent:

   
College/University:
City:
U.S. State/Territory:
Zip Code:
Country:
   
College/University:
City:
U.S. State/Territory:
Zip Code:
Country:
   
College/University:
City:
U.S. State/Territory:
Zip Code:
Country:
   
College/University:
City:
U.S. State/Territory:
Zip Code:
Country:

Miscellaneous Information

Have you been suspended or expelled for academic or disciplinary reasons? Yes   No
If you have, are you currently eligible to return to that institution? Yes   No
If yes, briefly explain the nature of suspension or expulsion:

Comments or Questions


Refer a friend

Who do you know that could be a good fit to take classes at the Shepherd University Martinsburg Center? Please list their contact information below and we will make sure they receive information.

Name:
Primary Phone:
E-mail:
Mailing Address:
City:
State:
Zip Code:
   
I certify that all statements in this application are complete and true. I understand that any willful misrepresentation of information may be grounds for denial of my admission and dismissal. Yes   No

Martinsburg Center | 261 Aikens Center | Martinsburg, West Virginia | 25404-6203 | 304-263-3303 | FAX 304-551-0089