OFFICE USE ONLY
Office of Admissions
419 College Drive Barnesville, GA 30204
678.359.5021 fax 678.359.5080
800.282.6504
www.gordonstate.edu
GCID#_________________________
Application for Admission
Date:__________________________
Application fee is $30. Please remit check or money order noting applicant’s name and SSN (preferred). CASH payments must be made in person.
The admissions application will not be processed until the fee has been paid.
PLEASE PRINT CLEARLY USING INK.
1.
Name:______________________________________________________________________________________________________________
Last Name
First Name
Middle Name
2.
Other last names that may appear on transcripts: ____________________________________________________________________________
3.
Mailing Address: _____________________________________________________________________________________________________
Street Address
Apt. #
City
State
____________________________________________________________________________________________________________________
Zip Code
County
Phone Number
4.
Social Security Number: ___________ - _____ - __________ *
Cell #__________________________________________________
5.
Email Address: _______________________________________________________________________________________________________
If you would like your parents to receive email updates on your admissions, financial aid, and housing status, please enter
parent’s email address: _______________________________________________________________________________________ (voluntary)
If you would like to receive information through social media, please include your handle for:
Twitter:______________________________ Instagram:_____________________________
6.
Date of Birth: _______ /_______ /_______
7.
Applicant’s sex:**
8.
Ethnic/Racial Group:**
Place:_________________________________________________________
City
□ Male
Check all that apply:
9.
Snapchat:_____________________________
□ Female
Marital Status:**
Are you Hispanic?
□ Yes
□ Married
State
□ Single
□ Separated
□ Divorced
□ No
□ American Indian / Alaska Native
□ African American
□ Native Hawaiian or Pacific Islander
□ Asian
□White
Residency Status: Georgia residence for fee-paying purposes requires 12 continuous months of domicile and residence in the state of Georgia
immediately prior to enrollment. A complete definition of the residence regulations may be found in the Gordon State College catalog.
Do you consider yourself a resident of Georgia as defined by the Board of Regents for fee-paying purposes?
How long have you resided in Georgia?
Are you applying for in-state tuition?
10. Citizenship status:
Years_____
□ Yes
□ No
Months______
□ No
□ U.S. Citizen by Birth □ U.S Citizen by Naturalization □ Non-Resident Alien
□ Resident Alien (Must provide Present Alien Registration Card to Admissions for verification)
11. Semester you plan to enroll: (Check one semester)
12. Year you plan to enroll: (Check one year)
13. Applying as: (check one)
□ Yes
□ 2016
□ Spring (January)
□ 2017
□ Summer (June)
□ Fall (August)
□ 20_____
□ Beginning Freshman
□ Transfer
□ Transient
□ Move On When Ready
□ Auditor
□ Post Baccalaureate Degree
□ 62 years or older
□ Weekend College (McDonough)
14. Intended Major: ______________________________________________________________________________________________________
15. List every high school and college/technical school attended in chronological order (attach a separate sheet if necessary). You must provide
official copies of your high school transcript and college transcripts of all colleges or post secondary institutions attended (if applicable). If you
are a GED applicant, the college requires that you submit an official score sheet from your GED exam. Failure to list complete and accurate
information may delay the application process.
Name of School
City and State
Did You Graduate?
Dates Attended
_____________________________________________________________________
___________
__________ to ___________
_____________________________________________________________________
___________
__________ to ___________
_____________________________________________________________________
___________
__________ to ___________
List any extracurricular activities or leadership positions: _____________________________________________________________________
____________________________________________________________________________________________________________________
16. APPLICATION CANNOT BE PROCESSED UNLESS THIS INFORMATION IS COMPLETE:
Have you ever been CHARGED WITH, convicted of, or have charges pending for a violation of any law other than minor traffic violations?
This includes first offender and a plea of no lo contendre. □ Yes (please explain) □ No
__________________________________________________________________________________________________________________________________
17. What is the highest level of education obtained by your parent(s)/guardian(s)?
Parent/Guardian 1:
□ Less than high school
□ High school diploma or equivalent (e.g., GED)
□ Some college but no formal award □ Certificate, less than an Associate's degree
□ Associate's degree (A.A., A.S., etc.) □ Baccalaureate degree (B.A., B.S., etc.)
□ Master's degree (M.A., M.S., etc.) □ Doctoral/Professional degree (Ph.D., M.D., J.D., etc.)
□ Unknown
Parent/Guardian 2:
□ Less than high school
□ High school diploma or equivalent (e.g., GED)
□ Some college but no formal award □ Certificate, less than an Associate's degree
□ Associate's degree (A.A., A.S., etc.) □ Baccalaureate degree (B.A., B.S., etc.)
□ Master's degree (M.A., M.S., etc.) □ Doctoral/Professional degree (Ph.D., M.D., J.D., etc.)
□ Unknown
18. If you did not graduate from high school, are you seeking admission on the basis of a GED?
19. Have you applied to Gordon State College previously?
□ Yes
□ No
20. What is your country of citizenship?___________________________
21. Is English your native language?
□ Yes
□ Yes
□ No
If Yes, please specify year and semester.______________
Country of birth?___________________________________
□ No
22. Do you plan to live on campus? □ Yes □ No
For additional information, including a residence hall application, please contact the office of Residence Life at 678. 359. 5435 or
online at http://www.gordonstate.edu/housing/
23. Emergency contact information?
□ Parent
Name:_______________________________
□ Guardian
□ Spouse
□ Other__________________________________________
Address:______________________________________________________________
Work Telephone: ______________________________________
Home Telephone: ______________________________________
24. For military experience credits, do you have a DD214 Form to submit for review?
25. U.S. Armed Forces Status:
Branch:
□ Air Force
Component:
□ Active
□ Yes
□ Current member □ Dependent of Current Member
□ Army
□ Coast Guard
□ Marines
□ Reserve
□ National Guard-Status:
□ No
□ Dependent of a Veteran
□ Navy
□ Discharged
□ Retired
□ Serving
26. For international students only:
Please indicate the kind of VISA you currently hold: _________________________________________________________________
27. Have you attended college or university level school previously?
28. Do you need an I-20 Certificate of Eligibility?
□ Yes
□ Yes
□ No
If yes, how many years did you complete: _____
□ No
29. Have you taken the Test of English as a Foreign Language (TOEFL)?
If so, when?______________________________________
□ Yes
□ No
where?___________________________________________________
I understand that any false statement made knowingly and willingly by me on this application, or any documents attached hereto may, in accordance with O.C.G.A. 16-10-71, which provides
that upon conviction, a person who knowingly commits the offense of false swearing shall be punished by a fine of not more than $1,000 or by imprisonment for not less than one nor more
than five years, or both, subject me to prosecution in a court of law. Additionally, I further understand that any such false statement may subject me to immediate dismissal from the institution.
Further, I certify that, to the best of my knowledge, the information submitted on this application is true and complete. By providing these telephone numbers, I understand, agree and give
express consent that Gordon State College or anyone working on their behalf, including third party vendors, may contact me at the number provided by manually dialing the number, by using
automated dialing technology or through SMS messaging.
By submitting this application, I agree to reimburse Gordon State College the fees of any collection agency, which may be based on a percentage at a maximum of 33% of the debt, and all costs
and expenses, including reasonable attorneys’ fees, we incur in such collection efforts.
By submitting this application, I consent to Gordon State College’s global consent to do business electronically where the primary method of communication is the student’s Gordon Email
account. This consent constitutes billing for charges, receipt of 1098-T tax form unless written request for paper form per instructions via Business Office webpage, late payment notices,
collections, and other student business related notices to be electronic.
In addition, I authorize Gordon State College to request a report of criminal records pertaining to the applicant which may be in the files at any criminal justice agency.
Applicant’s signature:_____________________________________________ Date:_________________________________________
It continues to be the policy of Gordon State College to implement affirmative equal opportunity to students and applicants for admission without regard to race, creed, color, sex, national
origin, religion, age, veteran status, or disability.
** Gordon State College is required to report sex, marital status and race/ethnic information to certain federal/state agencies as those data relate to civil rights compliance.
*Federal law recognizes the student Social Security number as personally identifiable information. However, the law allows the University System of Georgia to request and use this information according to federal and state guidelines as part of the student enrollment record. Your Social Security number is required when you apply for financial aid or for educational tax benefits. This information may be disclosed only under certain circumstances, including the following:
 To other institutional officials,
 To representatives of state and local educational authorities,
 In connection with financial aid,
 For research purposes to improve instruction,
 Pursuant to an order from a court of law,
 Other circumstances as required by state or federal law,
 To collection agents in connection with college-related
business.
10.12.2015