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Campus Safety Questions With App

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Application for Graduate Admission
Graduate College
1507 N Boulder Ave, Tomlinson 113
Russellville, AR 72801-2222
(479) 968-0398 Fax (479) 964-0542
http://graduate.atu.edu
Please Print
1.) Social Security Number 2.) Legal Name
______/______/______ Last__________________________ First____________________ Middle________________
3.) Other names used on academic records (if any) _________________________ T Number _________________________________
(If Applicable)
4.) Permanent Home Address
Street or Route and Box________________________________ City ________________________State _____________Zip_________
County _______________________Telephone Number (____)_____________
How long have you lived at the permanent address?________ If six months or less, list former address for the past six months and how
long you lived at each _____________________________________________
5.) Local Address (if different than permanent address) Street or Route and Box ________________________
City_________________ State ___________Zip_______ Telephone Number (____)__________________
6.) Emergency Contact Name
Last__________________________ First_______________________ Relationship___________________
7.) Emergency Contact Address (if different than permanent address)
Street or Route and Box_________________________ City ________________________State __________
Zip_________ Telephone Number (___)________________
8.) E-Mail address__________________________________________________________________________
9.) Date of birth
Month_______ Day_______ Year________
10.) Sex*
Male________ Female________
11.) Ethnic Origin* (Requested for reporting purposes only and will not be used to determine admission status)
1. ____African American, Non Hispanic
2. ____Native American/Alaskan Native
3. ____Asian American/Pacific Islander
4. ____Mexican American/Latin American/Hispanic
5. ____Caucasian
6. ____Non-Resident Alien
12.) ____U.S. Citizen ____Non-Resident Alien ____ Country of Citizenship ____Visa Type ____Expiration Date
_______________Card Number _____________Date Issued
*Voluntary information to be used in nondiscriminatory manner consistent with civil rights laws for reporting statistical purposes only and
cannot affect your eligibility for admission.
13.) Are you a legal Arkansas resident? _____Yes _____ No
To be classified as an Arkansas resident for University fee purposes, a student must have established a bona fide domicile in this state and
resided in the domiciliary status for at least six (6) consecutive months prior to the beginning of the semester for which fees are to be paid.
Contact the Office of Graduate College for additional information. All Arkansas counties, as well as, all contiguous states are considered
in-state for tuition purposes. Students who need to request accommodations made available through the Americans with Disabilities Act
should contact the Affirmative Action Office at (479) 964-3230.
14.) Have you ever enrolled for college courses, either as a full-time student, or a professional workshop? Yes ___No ___
If yes, list all the colleges where you have been enrolled, even if you did not complete a full term or receive a grade report. (Failure to list all colleges is considered falsification or
records and may result in cancellation of a student’s admission.) Attach additional sheets if necessary. Request each institution (other than Arkansas Tech University) to send an
official transcript to the Office of Graduate College.
UNDERGRADUATE
Name of College or University City and State Dates Attended Dates Conferred Degrees/Major
GRADUATE
Name of College or University City and State Dates Attended Dates Conferred Degrees/Major
15.) Semester for which you are applying for: Fall____ Spring____ Summer I____ Summer II____ of 20____
16.) Types of Admission (please read carefully)
_____Non-Degree Seeking
_____Transient – Seeking to complete coursework toward degree or certificate completion at transfer institution.
_____Degree Seeking – Applicants who plan to pursue a master’s degree at Arkansas Tech University must furnish OFFICIAL transcripts
from EACH college/university attended.
Indicate degree and area of specialization:
Master of Education Master of Engineering Master of Science Master of Liberal Arts
____Elementary Education ____Electrical Engineering option ____ Fisheries and Wildlife Biology ____Communications
Secondary Education ____ Mechanical Engineering option ____ Information Technology IT option ____The Fine Arts
____ English ____ Nuclear Engineering option ____ Information Technology IS option ____ Social Sciences
____ Physical Education ____ College Student Personnel
____ Instructional Technology Instructional Design & Technology option ____ Psychology
____ Instructional Technology Library Media option ____ Emergency Management and Master of Arts
____ Instructional Improvement Homeland Security ____English
____ Educational Leadership ____ Health Informatics ____ English with TESL
____ School Counseling and Leadership ____ History
____ Teaching, Learning, and Leadership Curriculum Administrator option Master of Science Nursing ____Multi-Media Journalism
____ Teaching, Learning, and Leadership Non-Traditional Teacher Leader option ____Administration ____Spanish
____TESOL
Educational Specialist ____ Teaching
____Educational Leadership
17.) Are you registered with the Selective Service? Yes_____ No_____
If no, are you (check one):
____ Female
____In the armed forces on active duty (members of the Reserves or National Guard are not considered active duty)
____Under the age of 18
____Born before 1960
____A permanent resident of the Trust Territory of the Pacific Islands or the North Mariana Islands
____An alien lawfully admitted to the United States as a non-immigrant
18.) Have you ever been convicted of a felony? Yes____ No____ (If yes, attach a separate sheet of paper explaining the circumstances)
19.) How did you hear about the Arkansas Tech University graduate program?
From alumni____ From friend____ Former ATU student____ ATU Homepage____ Other____________________________
I hereby affirm that all information supplied in these blanks is complete and accurate. It is my understanding that I shall not be considered
for admission to Arkansas Tech University until I have submitted all credentials specified. I understand that withholding information
requested or giving false information may make me ineligible for admission and enrollment.
Application’s Signature_______________________________________________________________Date_______________________________
Arkansas tech University does not discriminate on the basis on color, sex, race, age, national origin, religion, or disability in any of its practices polices, or procedures. This
includes, but is not limited to, admission, employment, financial aid or educational services, Arkansas Tech University complies with all applicable state and federal laws
including, but not limited to Title VI and Title VII of the Civil Rights Act of 1964 as amended, Title IX of the Educational Amendments of 1972, Section 504 of the Rehabilitation
Act Amendments of 1974, the Civil Rights Restoration Act of 1987, the Americans With Disabilities Act of 1990, and the Civil Rights Act of 1991. Social security numbers are
used as identification numbers for convenience and for consistency with our records. The Affirmation Action Office has been designated to coordinate compliance efforts.
Campus Safety Questions
Office of Graduate College ● Arkansas Tech University ● Tomlinson 113 ● Russellville, AR 72801-2222 ● 479-968-0398 http://graduate.atu.edu
Arkansas Tech University has amended the application for admission to include campus safety questions effective August 15, 2008. To be in
compliance with the current policy, you must accurately complete and return this form. Neither admission nor registration will be allowed until your
information has been received and evaluated.
Please print
Legal Name
First_______________________Middle_________Last________________________T#__________________
Address Number and Street or Route and
Box_______________________________City_____________________________State______________Zip__________
Phone Number (_____) _____________________ County________________Date of Birth _____/_____/_______
To maintain a safe learning community, we ask the following questions of all applicants. We cannot process your application unless
you answer these questions. Answering “yes” to one or more of the following questions will not necessarily preclude you from being
admitted. However, failure to provide complete, accurate, and truthful information will be grounds to deny or withdraw admission, or
to dismiss after enrollment.
1. Have you lived at your PERMANENT ADDRESS 6 months or longer? ___Yes ___No
If no, please list your previous address and length of residency. _____________________________________________________
2. Are you a current undergraduate Arkansas Tech University student? ___Yes ___No
3. Are you seeking licensure or certification only? ___Yes ___No
4. Are you registered with Selective Service? ___Yes ___No
If no, please tell us what category best describes you.
Female ____
In the armed forces on active duty (members of the Reserve and National Guard are not considered active duty) ___
Under the age of 18 ___
Born before 1960 ___
A permanent resident of the Trust Territory of the Pacific Islands or the Northern Mariana Islands ___
An alien lawfully admitted to the United States as a nonimmigrant. ___
5. Have you ever been convicted of, or pleaded no contest to, a crime other than a minor traffic violation? ___Yes ___No
6. Have you ever been expelled, dismissed, suspended, or placed on probation by any school (for non-academic reasons)?
___Yes ___No If yes, please give a brief explanation. _________________________________________________________
7. Do you have any criminal charges pending against you? ___Yes ___No
8. If you have ever served in the military, did you receive any type of discharge other than an honorable discharge? ___Yes ___No
9. Immunization records are not required for online students. Will you be taking online classes only? ___Yes ___No
You must promptly notify the Graduate College of any criminal charge, any disposition of a criminal charge, or any school, college, or
university disciplinary action against you, or any type of military discharge other than an honorable discharge that occurs at any time
after you submit this document.
I hereby affirm that all information supplied is complete and accurate. I understand that withholding information requested or giving
false information may make me ineligible for admission and enrollment.
Applicant’s Signture_________________________________________________________________Date______________________
Arkansas Tech University does not discriminate on the basis of color, sex, race, age, national origin, religion, or disability in any of its practices, policies, or
procedures. This includes, but not limited to, admission, employment, financial aid or educational services. Arkansas tech University complies with all
applicable state and federal laws including, but not limited to, Title VI and Title VII of the Civil Rights Act of 1964 as amended, Title IX of the Educational
Amendments of 1972, Section 504 of the Rehabilitation Act Amendments of 1974, the Civil Rights Restoration Act of 1987, the Americans With
Disabilities Act of 1990, and the Civil Rights of 1991. The Affirmative Action Office, Administration Building, Suite 200, has been designated to coordinate
compliance efforts.
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Campus Safety Questions With App

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Completed 6 March 2020

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