PO Box 7751 Havre, MT 59501 USA
Canadian Undergraduate Application for Admission
$30 (U.S.) Non-Refundable Application Fee Must Accompany this Application
Please Print or Type All Information
Personal Information ddddddddddddddddddddddddddddd ddddddddddddddddd
Complete legal name_________________________________________________________________________________________
Surname/Family First/Given Middle/Maiden
Birthdate (mo/day/yr) _______________________Birthplace_________________________________________________________
If you have ever been assigned a U.S. Social Security number, please indicate the number__________________________________
We ask that you voluntarily provide this number which permits MSUN to distinguish between individuals with similar names.
Mailing Address ____________________________________________________________________________________________
City _________________________ Province _______ Postal Code ______________ Cell Phone Number (____) _______________
Note - all admissions correspondence will be sent to this address; please notify us of any changes
Permanent Address __________________________________________________________________________________________
City _________________________ Province __________ Postal Code ________________ Phone Number (____) ______________
E-mail __________________________________________________
Country of Citizenship __________________________ Country of Permanent Residence _________________________________
Educational Information ddddddddddddddddddddd dddd dddddddddddddddddd
Term of Enrollment: Fall 20 ___________________ Spring 20 __________________ Summer 20 ___________________
Proposed field of study or major ________________________________________________________________________________
Please list all secondary and post-secondary schools attended:
Name of School
Type of
School
Address, City, Country
Dates of
Attendance
Name of
Degree/Diploma
1.
2.
3.
Students with Disabilities ccccccccccccccccccccccccccccccccccccc cccccccccccccccccccccccc
All students attending MSU-Northern are entitled to equal access to academic programs and services. By federal law, students with
documented disabilities are entitled to reasonable accommodations in order to fully participate in the student experience. All requests
regarding disability will be confidential and will not be used as a factor in granting or denying admission.
Would you like to be contacted by our disabilities services department? Yes No
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.
Signature ccccccccccccccccccccccccccccccccccccccccccccc
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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signature
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International Student Financial Certificate
Your application for admission will not be considered unless both statements below are completed. In addition, a bank statement or
other form of documentation must be provided for evidence of financial support to assure that funds are available for the first year of
study. Keep a copy of these documents for your records. It may be necessary to show verification of financial status at a U.S. port of
entry
.
I-20 Financial Requirements: US $15,720
Sponsors Statement
I, ______________________________________, do hereby guarantee that _____________________________________________
Name of Sponsor Name of Student
will have a minimum of $15,720 (fifteen thousand seven hundred twenty U.S. dollars) in addition to travel expenses for a round trip
from the student’s home to Montana State University-Northern for each calendar year that this person is a student at Montana State
University-Northern. I am also forwarding documentation to confirm that I have sufficient funds to sponsor this person.
Date ______________ Signed ___________________________________________________________________________________
mo/day/yr Sponsor’s Complete Legal Signature Relationship to Student Applicant
Applicants Statement
I certify that all statements on this form are true and accurate, and that funds will be provided as specified above. I will notify
Montana State University-Northern of any changes in my financial circumstances or in that of my sponsor. I understand that, should I
be admitted and register, failure on my part or on that of my sponsor to provide the needed funds will result in cancellation of my
registration and my termination from the undergraduate or graduate program at Montana State University-Northern.
Date______________ Signed___________________________________________________________________________________
mo/day/yr Applicant’s Complete Legal Signature
Voluntary Statistical Information ddddddddddddddddddddddddddddddddddddddddddd
Montana institutions of higher education using this application do not discriminate in admission or the provision of services nor
employment policies on the basis of race, gender, national origin, marital status, creed, religion, color, age or physical or mental
handicap. Providing the following information requested by this section is voluntary and the information provided is for statistical
analysis only.
Gender: Male Female Religious preference: ____________________________________________________________
Have either of your parent(s) or guardian(s) completed a bachelor’s degree? Yes No Unsure
Indicate your ethnic identity:
Hispanic or Latino
Not-Hispanic or Latino
Indicate all races that apply among the following:
White
American Indian (First Nation) or Alaska Native (specify primary tribal affiliation and reservation)_________________________
Black or African American
Asian (specify country of origin) _____________________________________________________________________________
Native Hawaiian or other Pacific Islander (please specify) _________________________________________________________
Other (please specify) ______________________________________________________________________________________
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