PSEO Program Application
Personal Information (please print)
Full Legal Name ______________________ _________________________ __________________________
Last First Middle
Permanent Address ________________________________________________________________________
Street Address City State Zip County
Student Cell Phone: ( ____ ) - ______ - _______ Home Phone Number: ( ______ ) - ________ - _________
Parent(s) Name: ____________________________________ Parent Cell Phone: ( _____ ) - _______- _______
Student Personal Email Address: _________________________________________
Social Security Number: ________-________- _________ Date of Birth: ____/______/_____
Month Day Year
Providing your SSN is voluntary. If you do not provide this number, your application will still be processed. Many colleges use Social Security numbers for student
identification purposes on internal student records. The number may be used for purposes of administration, program evaluation, consumer and alumni data, and also
may be used to create summary information about system programs through data matches with other state agencies.
High School Currently Attending _______________________________________________
HS Graduation Year __________
Are you a resident of Minnesota? _____Yes ____No If yes, how long? Years________ Months _________
Are you a United States citizen? _____Yes ____No If no, what is your status? ________________________________
Academic Data
The Minnesota PSEO Act promotes rigorous educational pursuits and provides a variety of options to 10
, 11
, and 12
grade high school students to enroll full-time or
part-time without tuition cost to them in nonsectarian courses or programs in eligible post- secondary institutions.
When do you plan to begin taking courses? ______Fall ______Spring Year _________
Do you plan to attend full-time or part-time? ______Full-time ______Part-time ______Undecided
What is your intended college major(s)? ___________________________________________
__Complete courses, but not a degree __Earn occupational certificate/ diploma
__Earn associate (two-year degree) __Complete courses and transfer without a degree
__Earn associate (two-year) degree and transfer
Demographic Information
Providing the following information is voluntary. This information will help Northland Community and Technical College evaluate student
recruitment and retention policies; it will not be used as a basis for admission.
Gender: ______Male _____Female
Are you Hispanic or Latino (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture, regardless of race.)?
_____Yes _____No
Racial background (select any that apply)
___American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central
America) who maintains cultural identification through tribal affiliation or community attachment.
___Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent.
___Black or African American: A person having origins in any of the black racial groups of Africa.
___Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific
___White: A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
What is the highest level of education for your parent(s)/guardian(s)?
Please respond for the parent(s), step-parent(s), adoptive parent(s) or guardian(s) who raised you. Check only one box for each parent/guardian.
Parent/Guardian #1
___No high school diploma ___High school diploma ___Some college ___Two-year college degree/diploma
___Bachelor’s degree or higher ___Not sure/don’t know
Parent/Guardian #2
___No high school diploma ___High school diploma ___Some college ___Two-year college degree/diploma
___Bachelor’s degree or higher ___Not sure/don’t know
Are you a dependent of someone who has served or is currently serving in the US armed forces? _____Yes _____No
Northland is asking you to provide information that includes private information under state and federal law. You are not legally required to provide
the information. However, the college may not be able to effectively process your application or registration if you do not provide sufficient
information. With some exceptions, unless you consent to further release of your private information, access to this information is limited to school
officials, including faculty who have legitimate educational interests in the information. Under certain circumstances, federal and state laws authorize
release of private information without your consent:
to other schools in which you seek or intend to enroll, or are enrolled;
to federal, state, or local authorities for purposes of education program compliance, audit, or evaluation;
as appropriate in connection with your application for, or receipt of, financial aid;
if the information is sought with a subpoena, court order, or otherwise permitted by other state or federal law; and
to an organization engaged in educational research or an accrediting agency.
Northland abides by the provisions of Title IX and other federal and state laws forbidding discrimination on the basis of sex, race, color, national
origin or handicap and all other federal and state laws regarding equal opportunity. This document can be made available in alternate formats, such as
large print or cassette tape, upon request by contacting Linnea Schluessler at 218-683-8560.
If you have been arrested, charged or convicted of any criminal offense, you should investigate the impact of the arrest, charge or conviction may
have on your chances of employment in the field you intend to study or on your chances to obtain federal, state, and other higher education financial
Northland Community & Technical College is a proud member of the Minnesota State system and is an Equal Opportunity employer and educator.
All of the information included is true and complete to the best of my knowledge.
Applicant’s signature Date
Northland Community and Technical College is an affirmative action, equal opportunity employer and educator.
This document is available in alternative formats to individuals with disabilities, consumers with hearing or speech disabilities may contact us via
their preferred Telecommunications Relay Service by dialing 711 (toll-free nationwide).
click to sign
click to edit