ENROLLMENT OBJECTIVES:
Desired year and semester of enrollment: __________________________(yr) Fall Spring Summer
Degree: Master Licensure Endorsement ABA Certificate Non-Degree
Proposed Degree/Certificate Program _______________________________________________________________________
EDUCATIONAL BACKGROUND:
List every college or university (including MSUB) you have attended or Enter dates of attendance (including present
Will attend prior to entering MSUB. Use a separate sheet if necessary enrollment and degrees earned or expected).
Dates of Attendance
***IMPORTANT***
YOU MUST READ AND SIGN THE FOLLOWING SECTION IN ORDER TO COMPLETE YOUR APPLICATION
If you answer YES to any of the following questions, you must attach an explanation regarding each circumstance.
Have you ever been convicted of a felony (include instances of deferred sentencing)? Yes No
Have you ever been subjected to court-ordered confinement for threatening or causing physical
or emotional injury to persons or property? Yes No
Have you ever been disciplined, suspended from, or placed on probation at any educational
institution for non-academic reasons? Yes No
Have you ever been required to register as a sexual or violent offender? Yes No
I certify that the information given in this application is complete and accurate to the best of my knowledge and understand that falsification or omission of information will be
sufficient grounds for refusal of admission or for dismissal. If admitted, I hereby agree to abide by the policies of the Board of Regents and the rules and regulations of Montana
State University Billings. Should any of the information I have given change prior to my entry to the university, I shall immediately notify the University. I understand the $40
check or money order I submit with this application is a nonrefundable fee.
________________________________________________________________________ _______________________________________________________________
Applicant’s Signature (sign complete legal name) Date of Application
**Ethnicity Hispanic or Latino **Race Asian Specify country of Origin _______________
Black or African American
Not Hispanic or Latino White
Native Hawaiian or Pacific Islander Specify country of origin _____________
Have you served in the military for a period of active duty American Indian or Alaskan Native
longer than 180 days? Yes No Specify primary tribal affiliation or reservation: ______________________________
**Federal requirements make necessary the collection of the above data for students. However, this information will not be used as a basis for admission.
***Pursuant to Titles VI and VII of the Civil Rights Act, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act, Executive Order 11246 as
amended, American With Disabilities Act of 1990, and the Montana State Human Rights Act – Montana State University Billings has a policy of nondiscrimination in employment
practices and in admission, access to, and conduct of educational programs and activities. Discrimination is prohibited on the basis of race, sex, color, national origin, religion, age,
disability, or marital status. Any student, employee, or applicant for admission may file a discrimination grievance. Inquires or grievances should be directed to the Human
Resources/EEO-AA director in McMullen Hall Room 310, 591010-0298, phone (406) 657-2278. For more detailed information please refer to
http://www.msubillings.edu/geninfo/upolicies.htm.
