1. Please Print or Type
2. Use Black or Blue Pen
3. Do not write in Shaded Areas
4. Abbreviate Where Necessary
The following official documents are required for Admission. Any
exceptions must have the registrar’s Approval.
1. Completed Application for Admission Form
2. High School and/or College Transcript(s), or High School Equivalent
3. Results from ONE of the following: ACT, SAT, or RSC Assessment
Battery may be required.
4. Birth Certificate, Social Security, or State/Federal Identification card
Rose State College
Student ID Number (7 digits)
First Name Middle Name Last Name Other Name(s) under which your records may appear
Office of Admissions and Records
6420 SE 15th Street
Midwest City, OK 73110
Resident Status: Resident of Oklahoma?
How long? Years Months
Born in the United States
Born Abroad on Military Base
Naturalized Citizen
Permanent Resident
F-1 Student Visa
Other Visa Type or Status
To Be Answered by U.S. and Foreign Students:
English is my second language?
*Official documents required by the U.S. Citizenship and
Immigration Service, Oklahoma State Regents, and Rose State College
must be received and evaluated before an I-20 will be issued.
The following information is optional but is requested for reporting purposes
only in accordance with the 1964 Civil Rights Act, Title VI, as amended.
Do you consider yourself Hispanic or Latino?
Select one or more of the following categories to describe you.
Non Resident Alien Asian
Black or African American White
American Indian Native Hawaiian
or Alaskan Native or Pacific Islander
Tribe Bloodline: Mother
Are you the first person in your immediate family to attend college?
Term Entering
Work Phone
Hours worked per week
Street Address City State County Zip Code
First Name Last Name Street Address City State/County Zip Code Phone Number
Social Security Number
Former RSC Student? Yes No Gender Male Female
Date of Birth
Month Day Year
Place of Birth
City State Country (if not U.S.)
Home Telephone Student’s Email Address
1. Active Duty U.S. Military:
2. National Guard or Reserves:
3. U.S. Military Veteran:
4. Dependent of National Guard or Reserve member:
5. Dependent of Active Duty U.S. Military member:
In what state is the active duty member stationed?
Were you (or are you the dependent of someone who was) discharged or released from Actve Duty military
service which lasted 90 days or longer within the past five years, currently residing in Oklahoma, and pursuing
a course of education under Chapter 30 (Montgomery GI Bill) or 33 (Post 9-11 GI Bill) VA educational benefits?
Yes No
Yes No
Supplying your Social Security Number enables a more expedient match of your test scores, transcripts, and financial aid benefits. You cannot receive Federal Financial Aid without providing
your Social Security Number.
Cell Phone
May we text you? Yes No
Yes No
Yes No
Year Entering
Yes No Branch of Service
Yes No Branch of Service
Yes No Branch of Service
Yes No
Yes No
Yes No
Citizenship Status:
If other status, please explain:
Application for Admission
I hereby affirm that all information supplied on this form is complete and accurate. It is my understanding that I shall not be considered for admission to Rose State College until I submit
all required documents. If I am accepted at Rose State College, I agree to abide by the rules and regulations of the College. I also understand that student records are released only in
accordance with institutional policy as provided by the Family Educational Rights and Privacy Act (as amended). As a student of Rose State College, I authorize all other previously
attended educational institutions to release to this college all records pertaining to my academic/student history. I understand that this institution may release student directory information
to other institutions, agencies or individuals unless I specifically, in writing, request otherwise.
Applicant’s Signature Date
Please list all colleges attended since graduation from high school, including current enrollment. List most recent college attended first.
Failure to list any colleges you have attended may result in loss of credit or dismissal from the College.
Name of Institution
City and State
Date Attended
From / To
Hours Earned
PS Code
(For Official Use Only)
High School Graduate:
Name of Last High School Attended
City State
County Code Resident Code Admit Code
PS High School Code
PS Code
(Last college Attended)
Month Day Year Admissions Use
Graduation Year Year Earned
Yes No
High School Equivalency Earned
Yes No
Have you attended any other colleges/universities?
Yes No
What was your academic standing at your last school? Good Probation Suspension
Educational Objectives
Anticipated major (s)
Please select the option or options that best describe your current goals:
Degree or Certificate Seeking:
I plan to earn an Associate degree at Rose State College.
I plan to earn a Certificate at Rose State College.
I plan to complete my basic coursework at Rose State College and earn a degree at a four-year university.
Non-Degree Seeking (Not Applying for Financial Aid)
I am a student at another college and taking one or more courses to transfer back to that college.
I am taking one or more courses for recreational or personal enrichment purposes.
I am taking one or more specific courses to help build and improve my job skills.
Disclaimer Statement
Rose State College is accredited by The Higher Learning Commission: A Commission of the North Central Association of Colleges and Schools, 230 South LaSalle Street,
Suite 7-500, Chicago, IL 60604-1411, Telephone: 1-800-621-7440. Rose State College does not discriminate on the basis of race, color, sex, age, national origin, religion,
disability, genetic information, sexual orientation, or status as a veteran in any of its policies, practices, or procedures. This includes, but is not limited to: admissions,
employment, financial aid, and educational programs, activities, or services. If discrimination, including harassment or retaliation, occurs, the College will take prompt and
appropriate corrective and remedial action. The person designated to handle inquiries regarding the nondiscrimination policies, including issues of noncompliance, is the Senior
Director, Human Resources/Affirmative Action Officer, 6420 SE 15th Street, ADM Room 104, Midwest City, OK 73110, (405) 733-7979. This publication is issued by Rose State
College, as authorized by the Board of Regents. 10,000 copies have been printed by Impressions Printing and distributed at a cost of $928.43.
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