Application for Re-admission
Personal Information
Name (Last, First, Middle or Maiden)
Date of Birth (mo/day/yr) SSN or Banner ID
Mailing Address
City State Zip Phone Number ( )
Cell Phone ( ) E-mail
Gender (optional): M F Ethnic Identity (optional): Hispanic Non-Hispanic
Indicate Race(s) (optional): White American Indian/Alaskan Native African American Asian Hawaiian Pacific Islander Other
Educational Information
Indicate term you plan to attend: Fall Semester______ Spring Semester______ Summer Semester______
Indicate Level: Undergraduate Graduate Intended Status: Degree-Seeking Non-Degree
Intended Degree/Major: Or Certification/Endorsement: Re-Certification
Traffic Ed
Indicate site planning to attend: Havre Great Falls Lewistown Other(Please specify):
Have you earned credit from any institution since last attending MSU-Northern? Yes No
If yes, list all post-secondary institutions attended, specifying campus and dates of enrollment.
Name of Institution
Location (City/State)
Attended From (mm/yyyy)
Attended To (mm/yyyy)
Credits/Degree Earned
Were you ever suspended or dismissed for academic reasons from any of the institutions listed above? Yes No If yes, (term/yyyy)
Residency Classification
U.S. Citizen Yes No If no, country of citizenship
In which state are you a resident of?
What year and state did you last pay taxes?
Required Safety and Security Information
Have you ever been convicted of a felony (include instances of deferred sentencing)? Yes No
Have you ever been subjected to court-ordered confinement for threatening
or causing physical or emotional injury to persons or property? Yes No
Have you ever been disciplined, suspended from, or placed on probation at any
post-secondary educational institution for non-academic reasons? Yes No
Have you ever been required to register as a sexual or violent offender? Yes No
An affirmative response to any of these questions will not automatically prevent admission, but you will be asked by the college to provide additional information. This information will
be reviewed by a campus committee to ensure campus safety. Any falsification or omission of data may result in a denial of admission or dismissal.
I hereby certify that to the best of my knowledge the foregoing information is true and complete without evasion or misrepresentation. I understand
that if it is later found otherwise, it is sufficient cause for rejection or dismissal. If my application for re-admission is approved, I agree to abide by the
present and future rules and regulations, both academic and nonacademic, and the scholastic standards of MSU-Northern including but not limited to
those rules, regulations and standards stated in the catalog. I further acknowledge that if I fail to adhere to these regulations or meet these
requirements, my registration may be canceled.
Applicants Complete Legal Signature Date
Questions: Call the Admissions Office at 1-800-662-6132 ext. 3704 or (406) 265-3704 FAX: 1-406-265-3792
Mail: Montana State University-Northern, Admissions, PO Box 7751, Havre, MT 59501