Missing or incorrect information will delay consideration of your application. Please print clearly.
NAME _________________________________________________________________________
Last Name First Middle Maiden
BIRTHDATE _______/_______/__________ _______________________________________________
SOCIAL SECURITY NO. Birth Date (Mo/Day/Yr) Social Security Number (required if applying for nancial aid)
LEGAL GENDER Legal Gender Male Female
Street Address City State Zip County
PHONE ( _______) ___________________________ ( _______) ___________________________
Home Phone Cell Phone
By providing you cell phone number, you are giving consent to receive text messages from Purdue University Northwest.
E-MAIL ADDRESS _________________________________________________________________________
ETHNICITY Hispanic or Latino Non-Hispanic or Non-Latino I prefer not to respond
RACE American Indian/Alaskan Native Asian Black or African American
Native Hawaiian or other Pacic Islander White I prefer not to respond
Check the appropriate boxes. (State and federal laws pertaining to civil rights require the university to report ethnic data.)
CITIZENSHIP United States Other (specify country) _____________________________________________
Permanent Resident Alien Number _________________ Visa __________________________
(Must provide front and back copy of your permanent resident card.) Type Expiration Month/Day/Year
International Asylee or Refugee None of the Above
(By selecting “None of the Above as my citizenship type, I understand that I am not eligible for in-state tuition.)
RESIDENCY Where have you been living for the past 12 months? (Show month, date and year) FULL DISCLOSURE REQUIRED
From: _____________ To: _____________ ______________________________________
(month/day/year) (month/day/year) Address (street, city, state)
PARENT/GUARDIAN _______________________________________________ _________________________
(If under 18) Last First Relationship
_______________________________________________ (_______)_________________
Number/Street City State Zip Phone
Have either of your parents earned a four-year college degree? Yes No (for research purposes only)
LEGACY INFORMATION Check any that have graduated from a PNW campus (Hammond or Westville) Father Mother Brother Sister
VETERAN STATUS Not a Veteran/Active Service I am a U.S. Veteran I am currently serving in the U.S. Armed Forces
I am a National Guard or Reserves enlistee who is on active duty for other than state or training purposes
Spouse of a veteran/enlisted member Widow of a veteran/enlisted member Child of a veteran/enlisted member
Are you a child of a disabled veteran? Yes No Are you planning to use Veteran Education Benets? Yes No
Check the appropriate boxes.
Hammond Campus • 2200 169th St. • Hammond, IN 46323 • (219) 989-2213 • (855) 608-4600
Westville Campus • 1401 S. US Hwy. 421 • Westville, IN 46391 • (219) 785-5505 • (855) 608-4600
admissions@pnw.edu • www.pnw.edu/admissions
DUAL CREDIT Have you taken college level credit courses as a High School Student? Yes No
ENTRY DATE What term are you applying for? Fall (August) Spring (January) Summer
Have you attended another Purdue campus? Yes No If yes, please specify last campus attended ________
DEGREE INTENT Do you plan to complete a degree at Purdue Northwest? Yes No
MAJOR Intended major ____________________________________ Concentration _________________
(2nd choice) Intended major _____________________________ Concentration _________________
* Nursing Deadline of February 1 for all applicants who wish to be considered for the following Fall semester direct admission or October 1 for
Spring semester direct admission. **If you currently hold an LPN License please submit a copy with your application.
HOME CAMPUS Please indicate the location at which you plan to attend the majority of your classes. Hammond Westville
HIGH SCHOOL INFO _________________________________________________________________________
Name City State
Graduation Year __________ GED or TASC completion date (if applicable) ________________
Are you a current recipient of Free or Reduced Lunch? Yes No (Please submit verication from Guidance Counselor)
SAT/ACT Indicate all date(s) you took or will take the SAT, rSAT and/or ACT __________ __________ ___________
SAT or rSAT (mo/yr) ACT (mo/yr) Neither
APPLICANT TYPE Freshman – I have graduated, or will graduate from high school and I have not earned college credit after graduating.
Transfer – I have attended a college or university after graduating high school.
Readmission – I previously attended a Purdue campus but was academically dropped from the university.
Re-Entry – I have previously attended a Purdue campus and was a student in good standing.
Regional Campus Transfer – I am currently attending a Purdue location and want to transfer permanently.
Non-Degree – I am pursuing courses for personal enrichment or am a visiting student taking courses at PNW.
Graduate Plus – I have completed a baccalaureate degree and plan to take additional undergraduate courses.
HIGHER EDUCATION Have you ever attended or are you currently attending another college? List the full name of all colleges you have attended.
Failure to indicate all institutions attended may result in denial of admission and/or termination of enrollment.
Institution City & State Dates attended Degree(s) earned Year received
If you have college credits from a non-Purdue University you must submit ocial transcripts from all colleges attended.
CAMPUS HOUSING Are you interested in living on campus? Yes No
EMERGENCY CONTACT __________________________________________________(_______)_______________
Last Name First Relationship Phone
Number/Street City State Zip
AUTHORIZATION I certify that all the information provided is accurate and true. I understand that falsied information may result in denial of admission and/or
SIGNATURE termination of enrollment at Purdue Northwest. I arm, under the penalties of perjury, that the following representations, including information
related to my citizenship status and/or presence in the United States, are true. I authorize Purdue Northwest to report my admission status and
academic program to my high school counselor for the purpose of curriculum development and improvement of instruction. I authorize secondary
and post-secondary schools I have attended to release information needed by Purdue Northwest to process and verify my application. I authorize
Purdue Northwest Division of Financial Aid to release, as it deems appropriate, information on my academic program (including grades) and the
amount of any nancial award I may receive to agencies, institutions, and others involved in providing funds for my education. I agree to abide
by the policies, rules and regulations of PNW.
_________________________________________________ (_______)_______________
Signature of Applicant Date Phone (during business hours)
A complete application will ensure the processing of your application as quickly as possible. All records submitted become the property of Purdue University.
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