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.
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.
Signature
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.
Applicant’s 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
