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Undergraduate Admissions Office, 1 University Circle, Macomb, IL 61455-1390 Undergraduate Application for Admission $30 Nonrefundable Application Fee Print neatly. This application will be scanned. Apply online at wiu.edu/admissions

PLEASE PRINT IN BLACK INK, USING CAPITAL LETTERS.

WIU ID NUMBER (OFFICE USE ONLY)

-- --

Legal last name

First name

M.I.

Indicate other name(s) you have used

Permanent home address (street number/space/street name/space/apt. number, if applicable)

City

State

Zip code

--

OFFICE USE ONLY Init. Date ACT/SAT

County

Male Female

Date of birth

Home phone (include area code)

--

Cell phone (include area code)

--

E-mail address (important information will be sent to this address)

Class AcSt

Mailing address (if different from permanent home address)

City SOCIAL SECURITY NUMBER

-- --

State

Zip code

-- Terms AHE

Please provide your social security number unless you are applying for admission under Illinois Public Act 93-7. Your social security number is required for financial aid purposes.

1. Are you requesting consideration for admission under Illinois Public Act 93-7 (Illinois Dream Act)? 2. Are you a U.S. Citizen or do you have a permanent residency card? Yes No If you have a permanent residency card, please submit a copy of the front and back of your card. If you selected No to question 2, complete the following: Country

Will you have completed a minimum of one year active duty in the U.S. military? (check one) If yes, submit copy of DD214--copy with status of discharge. National Guard or Reserve duty

Check one

Yes

No

H.S. 6 N College N Y

Type of Visa

Yes

--

To

No

--

7

G

Z G

Dates of service: No

--

From

--

8 --

Y ADST

Yes

Start date of basic training

--

F ADPR

Ethnic/Race Background: Your response to the following will assist our efforts to ensure race/ethnic compliance reporting with federal agencies. This information will not affect admission. 1. Please indicate if you are Hispanic/Latino: Yes No

2. Please indicate your race (select one or more as appropriate):

Black or African American

American Indian or Alaska Native White

Asian

School Code

Native Hawaiian or Other Pacific Islander

I am applying as: Freshman (student with no college work after high school graduation) Visiting Student (attending another college and wish to take classes at WIU for 1 semester only) Special High School Student (high school senior wishing to take college classes) Linkages (applying to enroll in both WIU and the following school)

Name of community college

Transfer (students who have taken 1 or more college class(es) since graduating high school) Non-Degree Seeking Student (high school graduate wishing to take classes but not for a degree) Dual Admission (applying now to attend WIU after attending the following school)

Name of community college

MT/Acct. Date

ACT/SAT GPA Rank

--OVER--

I am applying for: Campus applying for:

Intended major Teacher education

August (Fall)

January (Spring)

June (Summer)

Year:

Macomb Campus

Quad Cities campus

Have you previously applied to Western? Yes

Year

No

Yes

No

If yes, indicate month and year:

Month

In case of emergency, contact: Name Daytime phone (include area code) Address

Number and street

First

M.I.

Last

Suffix

--

Evening phone

City

--

State

Zip code

Emergency contact e-mail address Relationship: Parent Guardian Spouse Other Highest education your mother/guardian completed? (0) Unknown/Other (2) High School (4) Associates degree (2-year) (6) Graduate degree or more (1) Middle School/Junior High (3) Some College (no degree) (5) Baccalaureate degree (4-year)

Highest education your father/guardian completed? (0) Unknown/Other (2) High School (4) Associates degree (2-year) (6) Graduate degree or more (1) Middle School/Junior High (3) Some College (no degree) (5) Baccalaureate degree (4-year)

High school attending/attended High school city ACT was taken will be taken State SAT was taken

H.S. GRADUATION /

Month Year (or will complete)

GED EARNED /

Month Year

Month

Year

Month

Year

Month

Year

will be taken

Month

Year

*List ALL colleges or universities from which you have taken or plan to take courses prior to entering WIU. Official transcripts are required from all institutions. Name in chronological order.

OFFICE USE

School name City State Mo. From Yr. Mo. To Yr. Hours earned or to be earned from each school before entering Western

Degrees earned or anticipated (if any); institution where earned

Total hrs. Degree Institution Month

/

Year

A. All new freshman applicants are required to have their official ACT scores mailed to Western directly from Iowa City, Iowa, OR their official SAT scores mailed directly from Princeton, New Jersey. An official ACT/SAT score affixed to the transcript shall satisfy this requirement. Applicants in this category are also required to have their final official high school transcript, including date of graduation, mailed to Western directly from their high school upon graduation. B. An official transcript of credits must be mailed to Western directly from each college or university attended. Have transcripts mailed to: Undergraduate Admissions, Western Illinois University, Sherman Hall 115, 1 University Circle, Macomb, IL 61455-1390. C. Transfer applicants who plan to earn fewer than 24 semester hours (36 quarter hours) of credit prior to their planned enrollment date at Western are required to submit all documents as specified in both "A" and "B." Enclose your check or money order for $30, payable to Western Illinois University, for payment of the nonrefundable application fee. Do not send cash. If you qualify for an official fee waiver, please request the waiver form from your school counselor or financial aid officer and send the completed form along with your application. *This application must be signed and dated by the applicant before action can be taken. I understand that withholding information requested on this application or giving false information may make me ineligible for admission to the University or subject to dismissal. I certify that the information provided on the application is correct and complete. By signing this, I also certify that I have read, and will adhere to, all the components of the Criminal Record Disclosure Policy as stated.

SIGNATURE_____________________________________

Printed by authority of the State of Illinois · 8/2012 · 20,000 · 13037

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