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Personal Information
* NAME:
(First and Last required)
First:
Middle:
Last:
 
Preferred:
 
Former Name:
ENTRANCE TYPE: Degree Seeking
Non-Degree Seeking
MARITAL STATUS: Single
Married
Divorced

Spouse's Name:
* HOME ADDRESS & PHONE:
(Street, city, county, state, zip & phone are required)
Street:
Apt. #:
City:
County:
State:
Zip:
 
Phone:--
* E-MAIL ADDRESS:
** PLEASE NOTE: The college will correspond with you via email for most information. Please make sure the address above is checked daily.
SEX:Male
Female
* SOCIAL SECURITY NUMBER:--
* DATE OF BIRTH:
PLACE OF BIRTH:
CRIME RECORD:
If you have ever been convicted
of a crime, please explain.

Citizenship Information
* CITIZENSHIP STATUS: I am a U.S. citizen
I am not a U.S. citizen
I am a dual citizen (additional country)

Point of Contact
* HOW DID YOU HEAR ABOUT US?:
If other, please specify:

Optional Information
ETHNICITY: Hispanic
Non-Hispanic
RACE: American Indian or Alaska Native
Asian (Far East, Southeast Asia)
Black or African American
Native Hawaiian or other Pacific Islander
White
Other
RELIGIOUS PREFERENCE:
VETERAN:Yes
No

Academic Interests
* I PREFER TO BEGIN CLASSES IN:January
March
May
August
October
of
MAJOR/PROGRAM OF INTEREST:
Only one may be selected
Bachelor of Science in Business Administration with a speciality in Accouting & Finance
Bachelor of Science in Business Administration with a speciality in Organizational Management
Bachelor of Science in Criminal Justice

College Information
Indicate all colleges attended. This includes dual-credit courses taken while in high school.
COLLEGE 1 NAME:
COLLEGE 1 ADDRESS:
Address:
City:
State:
Zip:
COLLEGE 1 ATTENDANCE DATES
Begin:
End:
COLLEGE 1 DUAL CREDIT:
COLLEGE 2 NAME:
COLLEGE 2 ADDRESS:
Address:
City:
State:
Zip:
COLLEGE 2 ATTENDANCE DATES
Begin:
End:
COLLEGE 2 DUAL CREDIT:
COLLEGE 3 NAME:
COLLEGE 3 ADDRESS:
Address:
City:
State:
Zip:
COLLEGE 3 ATTENDANCE DATES
Begin:
End:
COLLEGE 3 DUAL CREDIT:
COLLEGE 4 NAME:
COLLEGE 4 ADDRESS:
Address:
City:
State:
Zip:
COLLEGE 4 ATTENDANCE DATES
Begin:
End:
COLLEGE 4 DUAL CREDIT:

Employment History
Indicate all employment (current and past) within the last 3 years.
EMPLOYER:
POSITION:
ADDRESS:
Address:
City:
State:
Zip:
PHONE:--
EMPLOYER:
POSITION:
ADDRESS:
Address:
City:
State:
Zip:
PHONE:--
EMPLOYER:
POSITION:
ADDRESS:
Address:
City:
State:
Zip:
PHONE:--

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Culver-Stockton College, One College Hill, Canton Missouri 63435  
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