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Term: Year 20__

Fall __________ 

Spring _________ 

Plan A/Host Pay ________Plan B/Home Pay ______  

NSE-MSU APPLICATION 

Personal Information

Full legal name __________________________________________________________________________________________________

Last                                                       First                                                   Middle

Social Security Number ______________________________________

We ask that you voluntarily provide this number which permits MSU to distinguish between individuals of the same or similar names. This is especially important should you request a transcript at a later date or which to be considered for fiancial aid.

Mailing Address *___________________________________________________________

___________________________________________________________

City                                           State                              Zip

*Note: this is where all mail will go, so please keep updated

Telephone (     ) _____________________________________ Student Cell: (    ) __________________________________________

Email ____________________________________________________

Birth date (mo/day/yr) and Birthplace  _____________________________ Country of Citizenship: _______________________

If not U.S., are you a permanent resident of the U.S.? (yes or no) _________________

 

 Voluntary Statistical Information

Gender:     Male      Female

 

Please indicate (by circling) if you are:

Hispanic or Latino (specify country of origin) ____________________________________________________

Not Hispanic or Latino

 

Please indicate (by circling) all races that apply among the following: 

White

Black or African American _______________________________________

American Indian or Alaskan Native (primary tribal affilitation and reservation) _____________________________

Asian (specify country of origin) _____________________________________________________

Native Hawaiian or other Pacific Islander (please specify) ______________________________________

Race/Ethnicity unknown _________________________________

Other (please specify) _____________________________________

 

Required Safety and Security Information (All applicants must complete this section)

1. Have you been convicted of a felony? (yes or no) _______________

A felony in Montana State law is defined as a crime for which more than one year in prison may be imposed.

2. Have you been subjected to court-ordered confinement for threatening or causing physical or emotional injury to persons or property? (yes or no) ___________________________

3. Have you been dismissed and/or suspended from a college for nonacademic reasons? (yes or no)

Suspension is defined as a sanction imposed for disciplinary reasons that results in a student leaving school for a specified time period. Dismissal from a college for disciplinary reasons is defined as permanent separation from an institution of higher education on the basis of conduct or behavior.

4. Have you ever been required to register as a sexual or violent offender? (yes or no) ______________________

If yes, please explain: 

 

An affirmative response to come of the questions will not automatically prevent admission, but you will be asked by the college to provide additional information. This information will be reviewed by a campus committee to ensure campus safety. Any falsification or omission of data may result in a denial of admission or dismissal.

                                                                                                     

Signature

I hereby certify that to the best of my knowledge the foregoing information is true and complete without evasion or misrepresentation. I understand that if found otherwise, it is sufficient cause for rejection or dismissal. If my application for admission is approved, I agree to abide by the present and future rules and regulations, both academic and nonacademic, and the scholastic standards of Montana State University, its colleges, schools, departments and institutes including but not limited to those rules, regulations and standards stated in the undergraduate/graduate catalog. I further acknowledge that if I fail to adhere to these regulations or meet these requirements, my registration may be canceled.

If I enroll at Montana State University, I agree to pay all tuition, fees, fines, and debts to the university that may be incurred by me. I understand that MSU will take action against me to collect any unpaid debts, including withholding of registration, transcripts and assignment of the debt for collection and I will be responsible to pay any costs incurred to collect the debt. If I fail to pay any tuition or fees when due, I understand the university will treat any unpaid amount as an educational loan extended to finance my education.

Applicant’s complete legal signature:

 

_________________________________________________________________________________________________________

Name                                                                                                                                    Date

 

RETURN THIS FORM TO:

Emily Mason

University Studies-Academic Advising Center

National Student Exchange

130 Gaines Hall

P.O. Box 173000

Bozeman, MT 59717-3000