Please complete this application form and return it to the Office of Admission along with a $50 application fee. If you have attended any
other schools since your last enrollment at Birmingham-Southern College, a transcript of your record at each school must be filed with
the Office of Admission. Please submit with this application a school recommendation form from the last college you attended. Please
print or type the answers to all questions.
Applicant for: Winter Spring Fall Summer Academic Year: _________________
Name: Miss. Ms. Mrs. Mr. _________________________________________________________________________________
Last First Middle
Preferred Name: _________________________ Cell Phone: ______________________ Student ID Number: ____________________
Current Address: _______________________________________________________________________________________________________
Number, Street, or P.O. Box City State Zip
Marital Status: Single Married Divorced Widowed If married, Spouses Name: _____________________________
Email Address: ____________________________ Veteran? Yes No Religious Preference: ___________________________
Parent’s Name(s): ______________________________________________ Cell Phone: ____________________________________________
Home Address: ________________________________________________________________________________________________________
Number, Street, or P.O. Box City State Zip
Classification of applicant: Freshman Sophomore Junior Senior Please indicate the date you left BSC: ____________
Reason: Medical Personal Military Academic __________________________ Other, (please specify):
Personal reason for leaving (please use reverse side if additional room is needed)
If your reason for leaving Birmingham-Southern College was medically-related, please submit a letter from your medical provider stating
that you are in good standing to return to BSC. If you desire residency on campus, this letter must also confirm your healthcare pro-
vider’s support of your request. This letter can be faxed to (205) 226-3074 or mailed to the Admission Office, 900 Arkadelphia Road,
Box 549008, Birmingham, AL 35254.
If your education has been interrupted for any reason, please describe in detail your activities since last enrolled.
Have you ever been found responsible for a disciplinary violation at any secondary school or college/university you have attended,
whether related to academic misconduct or behavioral misconduct, that resulted in your probation, suspension, removal, dismissal, or
Yes expulsion from the institution? No
Have you ever been convicted of a felony, misdemeanor, or any other crime? Yes No
If you answered yes to either or both of the above questions, please give the approximate date of each incident and explain the
List all colleges or universities that you have attended since your last enrollment at Birmingham-Southern College. Start with the most
recent enrollment:
College City, State Date Entered Date Left Graduated? (Date)
_______________________________________________ Expected major:
Are you requesting on-campus housing? Yes No
Will you apply for need-based financial aid? Yes No
Who was your advisor when you last attended Birmingham-Southern College? __________________________________________________
Please visit our website at or call (205) 226-4680 for more information.