Other Information cccccccccccccccccccccccccccccccccccccc ccccccccccccccccccccccccccccc
Parent(s)/Legal Guardian(s) Name_______________________________________________________________________________
Address ___________________________________________________________________________________________________
City _________________________________________ Province_____________ Postal Code______________________________
On a separate piece of paper, please provide the following information for each dependent accompanying you to the U.S.: family
name, first name, date of birth, country of birth, gender and relationship (spouse or child).
Required Safety and Security Information ccccccccccccccccccccccccccccccccccccccccccccc
Have you ever been convicted of a felony (include instances of deferred sentencing)? No Yes
Have you ever been subjected to court-ordered confinement for threatening or No Yes
causing physical or emotional injury to persons or property?
Have you ever been disciplined, suspended from, or placed on probation at any No Yes
post-secondary educational institution for non-academic reasons?
Have you ever been required to register as a sexual or violent offender? No Yes
An affirmative response to any of these questions will not automatically prevent admission, but you will be asked by the university 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.
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I hereby certify that to the best of my knowledge the foregoing information is true and complete without evasion or misrepresentation. I agree to
abide by the present and future rules and regulations, both academic and non-academic, and the scholastic standards of MSU-Northern, its colleges,
departments and institutes including but not limited to those rules, regulations and standards stated in the undergraduate/graduate catalog. I further
acknowledge that if I fail to adhere to these regulations or meet these requirements, my registration may be canceled.
If I am admitted to MSU-Northern, I agree to pay all tuition, fees, fines and debts to the university that may be incurred by me. I understand that
MSU-Northern will take action against me to collect any unpaid debts, including withholding of registration, transcripts and assignment of the debt
for collection, and I will be responsible to pay any costs incurred to collect the debt.
Applicant complete legal signature: ___________________________________________________________________________________________
signature date
Application Requirements dddddddddddddddddddddddddddddddddddddddddddddddd
The following materials should be submitted to Montana State University-Northern, Admissions Office, PO Box 7751, Havre, MT
59501 USA
Applicants must submit a complete Canadian Undergraduate Application for Admission.
A non-refundable application fee of $30 USD that can be paid with a credit card or international money order.
A statement of financial support that verifies that funds will be available to you to cover estimated costs of attendance
(in U.S. dollars) for one academic year. This reference letter or bank statement should be from a bank or financial institution
regarding funds of a financial sponsor, the student, or the parent/legal guardian.
Academic records for any secondary or port secondary institutions posting date of completion. Official records should
be sent directly from the school to MSU-Northern.
Students living in provinces in which English is not the primary language must show English proficiency by receiving a
score of 475 or higher (153 Computer based or 53 Internet based) on the Test of English as a Foreign Language (TOEFL) or
completion of English as a Second Language (ESL) Program, including ESL Language Centers, level 109.
Physician validated immunization record of mumps, measles (rubeola), and rubella (MMR) immunity. Diphtheria-
Tetanus (DT or Td), and skin testing for Tuberculosis, that was completed within one year of the planned attendance date.
This evidence must be presented before a student is permitted to register.
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