Online Application Form - Admissions Office / Adams State College

Prospective Students & Parents : Alumni : Current Students : Faculty & Staff : Distance Learning : Community & Visitors

Undergraduate Application for Admission
Please fill out all applicable information: (Required fields marked with an *) There is no need to rush in filling out this application. Take your time. The accuracy of the information you supply affects how quickly we can process your application. Please refer to our Web Privacy Policy regarding the information we collect in this application.

Personal Information:
*Term and year of expected enrollment at Adams State College:
Classification:	New Freshman Transfer Student Re-admit student
Full Legal name: *Last Name:
*First Name:
Middle Name:

*Date of Birth:	Month: Day: Year:
*Sex:	Male Female

Social Security Number: - -	*Your E-Mail Address:
The Social Security number will be used only for filing certain information returns with the IRS and to furnish a statement to you.
Permanent Address:

*Street:	*City:
*State:	*Zip:	-
Home phone number:	Work phone number:
Address to which admissions information should be sent, if different than above: (notify promptly if changed)

Street:	City:
State:	Zip:	-
phone number: -

Nation of Citizenship:
If not U.S., give temporary visa number:
Expiration date:	Month: Day: Year:
If a permanent resident of the U.S., give alien registration number
Date of Issuance:	Month: Day: Year:
Ethnic Origin: Please mark all that apply (disclosure is voluntary)

American Indian or Alaskan Native
Tribal Affiliation
Census Number
Asian
Black, African American, not of hispanic origin

Chicano, Hispanic, Mexican American, latino
Native Hawaiian or other Pacific Islander
White, not of Hispanic origin
Other
I do not wish to provide this info.

You must answer the question below.
*Have you ever been convicted of a crime? (misdemeanor Traffic violations are exempt)	Yes No
If you answered "YES", please explain the comment box below.

The following Selective Service questions must be answered to comply with the Colorado State Law:
*If you are a male born after December 31, 1959, are you registered with the Selective Service?	Yes No
Military Service:	Yes No
Active Duty Dates:	to
Are you eligible for veterans benefits:	Yes No

Additional Information:
Complete the following information for your (check one):	Parent Legal Guardian Spouse
Name: (Last, First, Middle)
Occupation:
Employer:
Home Address: (number & street)
City:
State:	Zip Code: -
Home Phone:
Work Phone:

College Plans:

What will be your proposed major(s) or field(s) of study?

1st choice:

2nd choice:

What is your educational
goal at this institution?

Associate degree
Bachelor's degree
Master's degree
Teaching Certificate
No Degree
Transfer

Indicate when you took (or plan to take) the college entrance exam(s):

ACT: month yr
SAT: month yr

List highest grade completed:

Type of school:

Public
Parochial
Private
Foreign

Last high school attended:

Name

City

State

Zip

Dates of attendance:

month yr
month yr

Date of Graduation:

month yr

If you are applying as a freshman, you must send official high school transcripts.

If not a high school graduate, have you earned a GED certificate?

Yes
No

Date:

month yr

State or agency:

You must submit a copy of your high school equivalency certificate and GED test scores.

College Education:
Have you attended, or are you currently attending another college?	Yes No
If Yes, completion of questions in this section is required.
Name of College/University:	State:
Dates of attendance: month yr to	month yr
Degree earned: Date:
Name of College/University:	State:
Dates of attendance: month yr to	month yr
Degree earned: Date:
Name of College/University:	State:
Dates of attendance: month yr to	month yr
Degree earned: Date:
Name of College/University:	State:
Dates of attendance: month yr to	month yr
Degree earned: Date:
Have you applied to or previously attended Adams State College?	Yes No
If yes, when?	month yr
Are you eligible to return to all institutions previously attended?	Yes No Not applicable
If you are not eligible to return, please provide a short explanation in the box below.

Residency Information:

Are you claiming tuition classification as a Colorado resident?

Yes
No

If yes, completion of all questions in this section is required. Failure to do so may result in your classification as a non-resident. Students who claim a change in tuition classification must contact the Office of Admissions and Records for further information. Dependents of non-resident active duty military personnel stationed in Colorado may request a tuition adjustment to in-state. For information, contact your Military Base Education Office.

Dates of continuous physical presence in Colorado (month/year):

(if you will be under 23 by initial enrollment date,
you'll need to fill in all the information for a parent as well.)

You:

From:
to:

Your Parent:

From:
to:

Dates of extended absences from Colorado (month/year):
(more than a month)

You:

From:
to:

Your Parent:

From:
to:

Reason for absence:

Last three years Colorado income taxes have been filed:

You:

20 ,

20 .

Your Parent:

20 ,

20 .

Dates of employment in Colorado (month/year):

You:

From:
to:

Your parent:

From:
to:

Date Colorado Drivers License was first issued (month/year):

You:

Your Parent:

Date current Colorado Drivers License was issued (month/year):

You:

Your Parent:

Last three years of Colorado Motor Vehicle registration:

You:

20 ,

20 .

Your Parent:

20 ,

20 .

Are you a registered voter?

You:
	Yes
	No

Your parent:
Yes
No

Date of purchase or lease of Colorado residential property (month/year):

You:

Your Parent:

Dates of Military Service, if applicable:

You:

Your Parent:

If your parents are separated or divorced, which one lives in Colorado?

Date of Marriage - answer this question if you will be under 22 by initial enrollment date.*

*Response to this question is voluntary, will not affect the admission process, and is used only to determine residency status.

STATEMENT OF CERTIFICATION

By entering your name, today's date and submitting the application, you are certifying that you are the person who has completed the information furnished on all sections of this application. You are certifying that to the best of your knowledge, the information furnished is true and complete. You understand that if found to be otherwise, it is sufficient cause for delay of admission, loss of credit, rejection or dismissal.

"I understand that by submitting this information via electronic transmission that I acknowledge the above statement of certification in lieu of a signature."

--all of these fields are required--

*First Name:
*Last Name:
*Todays Date:	mo. day: yr.


If you feel that any of the information you may have entered is incorrect, or you'd like to start over, click the button below.

For more information or to request application materials by mail, e-mail us: ascadmit@adams.edu or Phone (719) 587-7712 or (800) 824-6494. [ASC Home] [Admissions Home]