Nonrefundable $
25 application fee required with application. Please print
clearly, fill out completely using an ink pen (do not use a pencil) and return to
APSU Office of Admissions
Box 4548
Clarksville, TN 37044
Application for Undergraduate
Admission and Readmission
For Office Use Only
ID _____________________________
Term
__________________________
Date_________________________
Initials_______________________
1. Social Security number
nnn
-
nnn
-
nnnn
2. Name
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Last
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First
nnnnnnnnnnnnnnnnnnnnnn
Middle
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Previous name(s)/ Maiden name
Preferred name ________________________________________________
3. Permanent address (local address needed if military or dependent – do not use a unit address)
Street 1
nnnnnnnnnnnnnnnnnnnnnn
Street number and name
Street 2
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Apartment/Suite/P.O. Box Number (if applicable)
City
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State
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Zip
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Country
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Phone 1
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-
nnn
-
nnnn
Phone 2
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-
nnn
-
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Home Cell
4. Date of birth
nn nn nnnn
Month Day Year
5. Email
nnnnnnnnnnnnnnnnnnn
@
nnnnnnnnnnnnnnnnnn
.
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6. Gender (Optional) q Male q Female
7. Are you Hispanic/Latino?
q Yes q No
8. Select one or more race(s)
q White q Black or African American q Asian q American Indian
q Alaska Native q Native Hawaiian or other Pacific Islander
9. Are you a U.S. citizen? q
Yes
q
No
If no, list country of citizenship _______________________ Visa status or resident alien # ____________________
Country of birth ____________________________ If RA, submit a copy of your resident alien card.
10. Emergency contact information
Name _____________________________ Phone ( )____________ Relationship (optional)____________
Address ____________________________________________________________________________________________________________
Street/P.O. Box /Apt.# City State ZIP Code
11. Parent/guardian information (Required for anyone younger than 21)
Name _____________________________ Phone ( )____________ Relationship (optional)____________
Address ____________________________________________________________________________________________________________
Street/P.O. Box /Apt.# City State ZIP Code
12. Academic history (Please do not abbreviate.) An official transcript must be sent to the Office of Admissions.
q
Name of high school __________________________________________________________________
Are you home-schooled?
q
Yes
q
No
Graduation date Month ______________ Year ____________
City/State of high school _________________________________________________
Name under which transcript will be issued ___________________________________________________
q
Received a GED Date GED received ________________
Name under which GED scores will be issued _________________________________________________
13. Colleges and universities previously attended (Please DO NOT abbreviate.) List ALL colleges and universities
previously attended, including APSU (main campus and Fort Campbell), in chronological sequence.
14. Please indicate where and when you will first enroll (check one only)
Austin Peay main campus – Year 20
nn
q
Fall (August -December)
q
Spring (January - May)
q
Maymester (May)
q
Summer I (June)
q
Summer II (July)
Austin Peay Center @ Fort Campbell – Year 20
nn
q
Fall I (August -October)
q
Spring I (January - March)
q
Summer III (May - July)
q
Fall II (October -December)
q
Spring II (March - May)
Degree Dates Attended Name under which
Name of Institution City State
Earned (Month/Year) transcript will be issued
15 Do you plan to take classes at this off-campus
site?
q Austin
Peay at Highland Crest, Springfield, Tenn.
16. Entry level (check one)
q First-time student q Special student (see definition and q Readmit student; have attended
requirements in the current Bulletin) another college since APSU
q Transfer student; q Transient student, currently enrolled at q Readmit student; have not attended
first time at APSU another university (see definition and another college since APSU
requirements in the current Bulletin)
17. Residency (Please choose one of the following)
q I have lived continuously in Tennessee since __________________________.
q I have lived continuously in Allen, Calloway, Christian, Logan, Simpson, Todd or Trigg County in Kentucky
since ___________________.
q I have not lived continuously in Tennessee or the aforementioned Kentucky counties for the last 12 months.
q Fort Campbell military personnel claiming exemption from out-of-state tuition must provide military unit
address; whereas military family members must provide the name, Fort Campbell military unit address and
relationship to sponsor.
Name of Sponsor __________________________________________________________________________________________________
Relationship to Sponsor _________________________________________________
Military Unit Address __________________________________________________________ Base _______________________________
18. Housing preference q
On-campus resident q Off-campus commuter
See housing information on last page of this application.
19. Major Please indicate your intended major and concentration code
___________________________________________
20. Online courses
Are you enrolling in online courses only?
q Yes q No
Are you enrolling in the Regent’s Online Degree Program?
q Yes q No
Are you enrolling for online and
on-campus courses? q Yes q No
21. Are you seeking a second undergraduate degree?
q Yes q No
22. Are you seeking a postbachelor’s teacher certification?
q Yes q No
Application for Undergraduate
Admission and Readmission
(continued)
23. Selective Service registration
Consistent with the federal Military Selective Service Act, Tennessee law requires all male applicants to be registered with
the Selective Service (or certify exemption from the registration requirement) prior to enrolling in state colleges and
universities. You must certify compliance in section 1 below or indicate the basis upon which you claim
exemption in section 2 below. For more information, or to register online, please go to www.sss.gov.
1. I certify that I am registered with the Selective Service System as required by law.
q Yes q No
2. I certify that I am not required to be registered with the Selective Service System because:
q I am female. q I am a current member of the armed forces on active duty.
q I am younger than 18 years of age. q I was born before 1960.
q I am an exempt Resident Alien. q Other (Please specify)__________________________________
24. Active duty/Veterans/Family members
If you are active duty, an AARTS, SMART, DD 295 or CCAF transcript is required. If you are a veteran, a DD 214 Member
Copy 4 is required.
Date entered armed service ______________________________ Date separated ___________________________
Status (check one) Military I.D. expiration date Active duty use only
q Active duty q Month/Year _______/_______
(Family Members/Retirees do not complete)
q Family member Pay grade _________________________________
q Veteran Unit address _______________________________
q Retired veteran Military base __________________ State _______
Unit phone ________________________________
Years of service ____________________________
25. Please list the community leadership and/or extracurricular activities you have been involved in within the past
five years. (Please use extra sheet of paper if necessary)
_________________________________________________________________________________________
_________________________________________________________________________________________
26. Applicant acknowledgment
If you are accepted as a student at APSU, you will be required to take certain performance tests during your academic career. It is a require-
ment of admission that you agree to take any tests deemed necessary by the University. The purpose of this requirement is to comply with the
Tennessee Legislature’s expressed intent that institutions regularly evaluate and improve instruction at all levels. If you are under 21 years of
age and are required to complete academic assessment testing, your scores on these tests and course placement may be reported to your high
school for research purposes. Any test scores will be treated confidentially as required by law.
By my signature, I certify that the information supplied on this form is complete and true. I understand that falsifying information may lead to
disciplinary action and/or dismissal from the University. If accepted for admission, I agree to abide by all APSU rules and regulations as
printed in the Code of Student Conduct, Undergraduate Bulletin and other University publications.
Signature _______________________________________________ Date _________________________
How did you learn about APSU? (Check all that apply)
q Billboard q Family Member q Fort Campbell Education Center
q Friend q APSU Representative q Guidance Counselor
q Movie Ad q Newspaper q Radio
q Television q Commercial q Other ______________________________
Information for students with disability
If you have a learning or physical disability and want information on types of services and support that are available, please contact the
Office of Disability Services at (931) 221-6230 voice, (931) 221-6278 tty. It is recommended that students who may benefit from these
services make early contact with the office so that appropriate accommodations can be arranged.
