Gordon State College
Application for Readmission
419 College Drive
Barnesville, GA 30204
PHONE #: 678-359-5022
FAX #: 678-359-5382
1. Semester and year you plan to enroll: _________Fall
2. Applying as:
_______Freshman
_________Spring
_______Sophomore
_________Summer
_______Junior
_______Transient _______Joint Enrollment/Accel
_______Senior
_________Year
_______Transfer
_______Post-Baccalaureate _______Auditor
3. Gordon State College ID (929 # on front of ID card):_____________________OR Social Security No:_____________________
4. Name: ________________________________________________________________________________________
(First)
(Middle)
(Last)
5. Address: _______________________________________________________ Phone: ________________________
6. City: _______________________________________________ State: _____________ Zip Code: _______________
7. Name under which you last attended if different from current name: ________________________________________
8. Last term of attendance at Gordon:
9. Applicant's Sex: ____________
11. Ethnic/Racial Group:**
Check all that apply:
_________Fall
_________Spring
_________Year
10. Date of Birth:_________________________________________
Are you Hispanic? ______ Yes
______White
_________Summer
______ No
______Black or African American
______American Indian or Alaskan Native
______Asian
______Native Hawaiian or Pacific Island
**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.
12. Do you plan to live in a campus residence hall? _____Yes
_____No
13. Since last attending Gordon, have you resided out of the state? _____Yes
_____No
If yes, list where and provide dates of out-of-state residence. _____________________________________________
______________________________________________________________________________________________
14. Are you applying for in-state tuition? _____Yes _____No. How long have you lived in Georgia?_____Years
_____Months
15. List major program of study you plan to pursue: _______________________________________________________
16. List all colleges and universities attended since you last attended Gordon and date(s) of attendance. If none, please
write “None.” (Transcripts of all other colleges must be submitted directly to the Office of the Registrar from the
colleges attended.)
Name of School
Dates Attended
Academic Standing
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
17. Are you currently enrolled in the last institution you attended? _____Yes
_____No
*** APPLICATION CANNOT BE PROCESSED UNLESS QUESTION 18 IS COMPLETED.***
18. Have you ever been charged with, convicted of, or have charges pending for a violation of any law other than minor
traffic violations?_____No _____Yes (Please explain) _________________________________________________
_____________________________________________________________________________________________
CONTINUED ON PAGE 2
APPLICANT’S SIGNATURE REQUIRED ON PAGE 2 FOR PROCESSING.
Rev. 4-3-14
Page 1 of 2
19. U.S. Armed Forces Status:
Current member ■ Dependent of Current Member ■
Dependent of a Veteran
Branch:
Air Force ■
Army ■
Coast Guard ■
Marines ■
Navy
Component:
Active ■
Reserve ■
National Guard
Status: ■
Discharged ■ Retired ■
Serving
I have no Armed Forces status as a service member or as a dependent of a service member.
Verification of Lawful Presence Requirement
**PLEASE NOTE THAT YOUR APPLICATION FOR READMISSION WILL NOT BE PROCESSED UNTIL THIS INFORMATION IS RECEIVED**
In order to comply with policies of the Board of Regents of the University System of Georgia, Gordon State College must verify the
lawful presence in the United States of every student seeking resident tuition status, as defined in Section 7.3 of the Board of
Regents Policy Manual. This requirement applies to all applicants for admission or readmission to Gordon State College.
Please submit one of the following items to the Registrar’s Office to verify your lawful presence:
•
A current Driver’s License issued by the State of Georgia after January 1, 2008. (Scan and email the front and back of
your license to the Registrar’s Office or bring your license to the Registrar’s Office to be copied. We cannot accept a
faxed copy of a driver’s license.)
•
A current ID issued by the State of Georgia after January 1, 2008.
•
A current U.S. military ID (May be provided for service member only. Not acceptable for a military dependent.)
•
A current U.S. Passport
•
A U.S. Certificate of Citizenship (USCIS form N-560 or N-561)
•
A U.S. Certificate of Naturalization (USCIS form N-550 or N-570)
•
A current, valid Permanent Resident Card (USCIS form 1-151 or I-551)
•
A Certified U.S. Birth Certificate showing that you were born in the U.S. or a U.S. territory. A photocopy is not
acceptable.
•
A U.S. Certificate of Birth Abroad issued by the Department of State (DS-1350 or a Consular Report of Birth Abroad
(FS-240).
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.
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 providing this telephone number, 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 or by using
automated dialing technology.
I understand that any material 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.
I CERTIFY that the information contained in this application is true and correct. I understand that misrepresentation or omission of
information will be sufficient cause for rejection or dismissal. 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__________________
Rev. 4-3-14
Page 2 of 2