First Name
Last Name
Middle Name
Gender
Prefered Name, if not first name
Former last name (If any)
Email Address:
IM Address
Permanent Street Address
Appartment #
City
State/Province
Country
Zip/Postal Code
Permanent Home Phone Number
Cell Phone Number
Date of birth mm/dd/yyyy
(Kentucky Residents Only) State ID#
CITIZENSHIP
If you are not a US Citizen and live in the United States, how long have you been in the country?
Do you intend to apply for financial aid?
Place of birth, City
State/Province
Country
Social Security Number
First Language if other than English
Primary Language spoken at home
US Armed Services Veteran
Marital Status:
If Divorced (Date) mm/dd/yyyy
If you wish to be identified with a particular ethnic group, please check all that apply:
Parents Marital Status
If divorced (date) mm/dd/yyyy
With Whom do you make your permanent home?
If Other, whom?
Is Parent/Gardian 2 living?
Parent/Gardian 1
Parent/Gardian 1 last name
Parent/Gardian 1 first name
Parent/Gardian 1 address is different from yours
Parent/Gardian 1 Home Phone #
Parent/Gardian 1 E-mail
Parent/Gardian 1 Occupation
Parent/Gardian 1 Name of Employer
Parent/Gardian 1 College (if any)
Parent/Gardian 1 Degree?
Parent/Gardian 1 Graduate School (if any)
Parent/Gardian 1 Degree?
Parent/Gardian 2
Parent/Gardian 2 last name
Parent/Gardian 2 first name
Parent/Gardian 2 Home address if different from yours
Parent/Gardian 2 Home Phone #
Parent/Gardian 2 E-mail
Parent/Gardian 2 Occupation
Parent/Gardian 2 Name of Employer
Parent/Gardian 2 College (if any)
Parent/Gardian 2 Degree?
Parent/Gardian 2 Graduate School (if any)
Parent/Gardian 2 Degree?
Please give names and ages of your brothers or sisters. If they have attended college, give the names ot the institution, degree earned, and approximate dates of attendance.
High School
Year Graduated?
Name of High School
Address, City, State, Zip
Name of high School Counselor
When do you plan on entering college?
If other, when?
Degree plans
If other, what?
What do you intend to study as a Major?
What do you intend to study as a Minor?
Full Time?
Housing plans?
Colleges previously attended
Name, address, city, state dates attended and degree earned of college 1
Name, address, city, state dates attended and degree earned of college 2
Briefly describe any acedemic distinctions or honors you have won since the 9th grade (e.g. National Merit, Cum Laude society)
Please list your principle extracurricular, community, and family activities and hobbies in the order of their interest to you. Include specific events and/or major accomplishments such as musical instrument played, varsity letters earned, etc. To allow us to focus on the highlights of your activities, please complete this section even if you plan to attach a resume'.
Religeous Affiliation (Required)
Name or church
Name of Pastor
How did you hear about Mid-Continent University?
Do you know anyone who currently attends or who has attended Mid-Continent University?
If yes, who? Please list thier name(s) and your relationship to you.
To which other colleges are you applying?
Have you visited Mid-Continent University?
In your own words, describe why you are choosing to attend a Christian college and what you wish to receive from a Christian Education. Please respond with a document double spaced, typewritten format on one page. Upload the document using the browse button. Be sure to include your name and address on this attached page.
Please submit one personal reference letter. It may be a teacher, principal, community leader, etc. but not a family member, and has known you for at least two years.
Have you ever been found responsible for a disciplinary violation at an educational institution you have attented from 9th grade (or the international equivalent) forward, whether related to academic misconduct or behavioral misconduct, that resulted in your probation, suspension, removal, dismissal, or expulsion from the institution?
Have you ever been conviceted of a misdemeanor, felony, or other crime?
If you answered yes to either of the last two questions please give the dates and explain the circumstances of the incidents.
Is there any additional information you'd like to provide regarding special circumstances, additional qualifications, etc?
I certify that the above information is true and complete. Any falsification or omission of information may be grounds for denial of admission or expulsion. I agree to pay tuition, fees and other bills, and comply with the rules and regulations set forth by Mid-Continent University. Type you name here:
Today's date: (Format = month/day/year) eg 01/25/2012
Online Promotion Code: (If you have one)
