UNDERGRADUATE
APPLICATION
FOR
ADMISSION
wiu.edu
Return to: Undergraduate Admissions Office
1 University Circle
Macomb, IL 61455-1390
$30 Nonrefundable Application Fee
Apply online at wiu.edu/admissions/apply_now
WIU ID NUMBER (OFFICE USE ONLY)
PLEASE PRINT IN BLACK INK, USING CAPITAL LETTERS.
—
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
—
County
Male Female
Home phone (include area code)
Date of birth
Cell phone (include area code)
—
—
E-mail address (important information will be sent to this address)
OFFICE USE ONLY
Mailing address (if different from permanent home address)
Init.
City
State
Date
Zip code
ACT/SAT
—
SOCIAL SECURITY NUMBER
—
—
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)?
Class
Yes
No
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
Dates of service:
If yes, submit copy of DD214—copy with status
of discharge.
National Guard or Reserve duty
Yes
Check one
—
Yes
—
No
—
From
No
AHE
Type of Visa
Will you have completed a minimum of one year active duty in the U.S. military? (check one)
—
To
Start date of basic training
—
H.S.
—
6
N
7
G
8
Y
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
Native Hawaiian or Other Pacific Islander
Asian
Transfer (students who have taken 1 or more college
class(es) since graduating high school)
Visiting Student (attending another college and
wish to take classes at WIU for 1 semester only)
Non-Degree Seeking Student (high school graduate
wishing to take classes but not for a degree)
Special High School Student (high school senior
wishing to take college classes)
Dual Admission (applying now to attend WIU after
attending the following school)
Name of community college
Name of community college
—OVER—
College
N
Y
White
I am applying as:
Freshman (student with no college work after high
school graduation)
Linkages (applying to enroll in both WIU and the
following school)
AcSt
Z
G
ADST
F
ADPR
School Code
I am applying for:
August (Fall)
Campus applying for:
January (Spring)
Macomb Campus
June (Summer)
Year:
Quad Cities campus
Intended major
Have you previously applied to Western?
Teacher education
Yes
No
If yes, indicate month and year:
In case of emergency, contact: Name
First
Address
Month
No
Year
M.I.
—
Daytime phone (include area code)
Yes
Last
Suffix
—
Evening phone
Number and street
City
State
Zip code
Emergency contact e-mail address
Relationship:
Parent
Guardian
Spouse
Other
Highest education your father/guardian completed?
Highest education your mother/guardian completed?
(0) Unknown/Other
(1) Middle School/Junior High
(0) Unknown/Other
(1) Middle School/Junior High
(2) High School
(3) Some College (no degree)
(2) High School
(3) Some College (no degree)
(4) Associates degree (2-year)
(5) Baccalaureate degree (4-year)
(4) Associates degree (2-year)
(5) Baccalaureate degree (4-year)
(6) Graduate degree or more
(6) Graduate degree or more
H.S. GRADUATION
High school attending/attended
High school city
ACT was taken
Year
will be taken
Month
Year
SAT was taken
/
Month
Year
(or will complete)
State
Month
GED EARNED
/
Month
Month
will be taken
Year
Month
Year
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
Degrees earned or anticipated (if any);
institution where earned
City
State
Mo.
From
Yr.
Mo.
To
Yr.
Hours earned or to be
earned from each school
before entering Western
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.”
Criminal Record Disclosure
Western Illinois University is committed to maintaining a safe and positive environment for
all members of the University community. Therefore, you are required to disclose information
regarding your criminal or disciplinary background.
1. Yes
No
Have you ever been convicted of, or been placed on court supervision for, any
criminal offense? (This does not include routine traffic offenses.)
2. Yes
No
Do you have any criminal charges pending against you?
3. Yes
No
Have you ever been dismissed, or withdrew while charges were pending, from
any educational institution (including, but not limited to, high school or college) for any offense
involving violence or the threat of violence?
If you answered “yes” to any of the questions above, please submit a description of the incident(s),
including name, date of birth, date of incident(s), location of incident(s), name of arresting
agency(ies), as well as any additional relevant documentation. Additionally, please request the
Circuit Clerk of the Court(s) in which the order of conviction(s) was entered and forward record(s)
to:
Western Illinois University, Sherman Hall Room 117, 1 University Circle, Macomb, IL, 61455,
attention to Campus Violence Prevention Enrollment Committee. These cases will be reviewed
prior to an admissions decision being made. Such disclosures do not automatically disqualify an
applicant.
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.
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 • 8/2013 • 10,000 • 14012
Date
Month
Day
Year