Online Student Application

1. Start Term *: Select One 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Spring 2040 - Summer 2040 - Fall
   Note: Select when you would like to start your services.
2. Primary Campus *: Select One Clifton Columbia Campus Lawrenceburg Lewisburg Williamson
   Note: Please select campus location where you will be enrolled.
3. Expected Graduation Term: Select One 2011 - Spring 2011 - Summer 2011 - Fall 2012 - Spring 2012 - Summer 2012 - Fall 2013 - Spring 2013 - Summer 2013 - Fall 2014 - Spring 2014 - Summer 2014 - Fall 2015 - Spring 2015 - Summer 2015 - Fall 2016 - Spring 2016 - Summer 2016 - Fall 2017 - Spring 2017 - Summer 2017 - Fall 2018 - Spring 2018 - Summer 2018 - Fall 2019 - Spring 2019 - Summer 2019 - Fall 2020 - Spring 2020 - Summer 2020 - Fall 2021 - Spring 2021 - Summer 2021 - Fall 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Spring 2040 - Summer 2040 - Fall
   Note: Select when you plan to graduate.
4. First Name *:
5. Last Name *:
6. Middle Name:
7. Optional: Preferred Name:
8. Student ID:
   Hint: Enter 9 alpha numeric characters.
9. Birth Date:
   Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
10. Gender *: Select One Female Male Not Specified

1. Primary Phone Number:
   Hint: Enter 10-digit number only.
2. Secondary Phone Number:
   Hint: Enter 10-digit number only.
3. Email Address *:

1. Address *:
2. City *:
3. State *: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode *:
   Hint: Enter zipcode as 97331 or 97331-0000.

Same as Local Address

1. Address:
2. City:
3. State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode:
   Hint: Enter zipcode as 97331 or 97331-0000.

1. Primary Disability *: Select One === General Category === ADHD/ADD Anxiety Autism Deaf/Hard of Hearing Diabetes Medical condition Other PTSD TBI === Learning Disability === Dyslexia Learning Disabilty === Mental Health === Bipolar === Vision === Blind/Visual impaired
2. Secondary Disability(ies)

   General Category

   ADHD/ADD

   Anxiety

   Autism

   Deaf/Hard of Hearing

   Diabetes

   Medical condition

   Other

   PTSD

   TBI

   Learning Disability

   Dyslexia

   Learning Disabilty

   Mental Health

   Bipolar

   Vision

   Blind/Visual impaired
3. Other Disability or Note:
4. Seeking Degree: Select One Associate of Applied Science Associate of Arts Associate of Science Certificate Dual Enrollment Non-degree seeking Transient Undergraduate
5. Major: Select One Accounting Advanced Integrated Industrial Technology Agriculture Animal Science Anthropology Art Biology Business Administration Chemistry Commercial Entertainment Computed Tomography Computer Networking Criminal Justice Dental Hygiene Early Childhood Education Economics Emergency Medical Services EMT Engineering English Exercise Science Film Crew Technology Finance Foreign Language General Transfer Geography Graphic Design History Hospitality and Tourism Management Humanities Information Systems International Affairs Management Marketing Mass Communication Mathematics Medical Informatics Music Nursing Nutrition Philosophy Physical Education Physics Plant and Soil Science Political Science Pre-Allied Health Psychology Public Relations Rad Tech Respiratory Care Social Work Sociology Special Education Speech Communication Sports Management Teaching Theater Vet Tech

Affiliation(s)

6. Affiliation(s)

   CLS--College Living Experience

   SSI/SSDI Recipient

   TRIO

   Vocational Rehabiliation

Ethnicity(ies)

7. Ethnicity(ies)

   African-American

   Asian or Pacific Islander

   Caucasian

   European-American

   Hispanic

   Multi-Racial

   Native American

   Other

Campus Location(s)

8. Campus Location(s)

   Clifton

   Columbia Campus

   Lawrenceburg

   Lewisburg

   Williamson
9. Additional Note: