___________________________________________ ___________________________________________
HIGH SCHOOL INFO _________________________________________________________________________
Name City State
Graduation Year __________
Are you a current recipient of Free or Reduced Lunch? Yes No
(Please submit verication from Guidance Counselor)
TO BE COMPLETED BY STUDENT AND PARENT
Please read carefully and sign:
1. I certify that the information I have provided on this application is accurate, true and complete.
2. I agree to abide by the policies, rules and regulations of Purdue University Northwest.
3. I authorize my high school to furnish all academic and personal information requested by the Oce of Admissions of Purdue University Northwest.
4. I authorize Purdue University Northwest to report my academic progres to my high school.
5. I understand that my enrollment will be limited to courses approved by Purdue University Northwest academic advisors.
Applicant Signature Date of Signing Parent Signature Date of Signing
TO BE COMPLETED BY HIGH SCHOOL STAFF
1. I have been informed that __________________ plans to enroll for classes at Purdue University Northwest for the
Student Name
Spring (January) Summer Fall (August) semester
2. Please be advised that the above mentioned student has my approval to enroll for: College Credit only Dual credit (h.s. /college credit)
3. This student ranks __________ in a class of __________.
4. This student’s test scores are _______/_______ PSAT SAT ACT
Verbal Math
5. Will this student be a recipient of the FREE LUNCH or REDUCED LUNCH PROGRAM for the college term in which they applied? yes no
* The student must show documentation to support they are currently receiving free lunch assistance
__________________________________________ or __________________________________________
Principal Signature Date of Signing School Counselor Signature Date of Signing
Students with Disabilities
Why We Want To Know
Purdue University Northwest is committed to providing equal access and equal opportunity
Although reporting your Social Security Number (SSN) to Purdue University Northwest is not
to University courses, activities and programs for students with disabilities. Students with
required and your SSN will not be used as your Purdue student identication number, it is
documented disabilities that substantially limit a major life activity, such as learning, walking
required to receive certain federal tax benets. Additionally, the SSN is helpful to accurately
or seeing, may qualify for academic adjustments and/or services. To request information
match your application with other records such as SAT or ACT scores. Disclosure of your SSN will
about academic adjustments, auxiliary aids, or services, please refer to the Disability Access
be restricted to University business processes, such as those required for federal and state
Center web site at www.pnw.edu/access/.
reporting as well as institutional purposes. By providing your SSN, you authorize the university
to disclose it to these agencies.
Equal Access/Equal Opportunity University
Purdue University Northwest is an equal access/equal opportunity university. No qualied
Security on Campus
person will be denied admission or employment, nor will any student or employee be subjected
Purdue University is committed to assisting all members of the campus community in providing
to discriminatory treatment or be excluded from participation in any educational program or
for their own safety and security. The University prepares an Annual Security Report containing
activity on the basis of race, religion, color, sex, age, national origin, disability, or status as a
statistics and information relating to campus safety and security policies and programs. All
disabled veteran.
admitted students will receive Purdue University Northwest Annual Security Report Notice.
