General Information
Please Type or Print Legibly-Items marked with an *are required
Social Security Number: ________ — ____ — ________
(Your SSN is not required for admission to the college, but is required to apply for financial aid)
*Full Legal Name:
Last:____________________________ Suffix:______ First: ___________________________ Middle Name: _________
*Mailing Address: Street:______________________________________________________________________________
City:________________________________________ State: __________ Zip Code:______________________________
*Gender:
*Date of Birth:
Male
Female
Month ______ Day ______ Year ______
Place of Birth: _____________________
Home: _____________________
Work: _____________________
Cell: _____________________
*Email: _________________________________________________________________________________________________________
Do you intend to apply for financial aid?
*Citizenship:
U.S. Citizen
Military Status:
Yes
No
Valid Visa Holder
Active
Non Resident
Reserves
Non Resident Alien/Undocumented
*Emergency Contact:
Last:________________________________________ First: ______________________________ Middle Initial: ______
Relationship: __________________________________
Telephone Number: (_______) - _______- __________ Alternate Phone: (_______) - _______- __________
Address: Street:______________________________________________________________________________________
City:________________________________________ State: __________ Zip Code:______________________________
Are you Hispanic/Latino?
Ethnic Affiliation:
Choose
one or more.
Yes
No
American Indian
Alaska Native
Native Hawaiian or Other Pacific Islander
*Educational background
Asian
White
Black or African American
Other
for High School Graduates or GED recipients
School Name: ______________________________________________________________________________________
City or County: __________________________________
Month/Year of Graduation/GED Earned: ______________________________________________________________
*Educational background
for High School Seniors expecting to graduate
School Name: ______________________________________________________________________________________
City or County: __________________________________
Month/Year of Expected Graduation: _________________________________________________________________
*Educational background
for students who do not and will not have a high school diploma or GED
Name of last school attended: ________________________________________________________________________
City or County: __________________________________
Highest grade completed: _________________________________________________________________
*Education objective
Intended Term of Enrollment:
Fall (Aug.-Dec.)
Have You Attended Ivy Tech Previously?
If yes, when: _______________________________
Spring (Jan.-May)
Summer (May-Aug.)
YEAR: ______________
Yes No
Which Location: _______________________________________________
Applying for:
Those enrolled in Courses Only/Non Degree & Career Development Certificate Programs are not eligible for Federal/State Financial Aid
Associate
Associate
Associate
Associate
of
of
of
of
Applied Science
Arts
Fine Arts
Science
Certificate
Technical Certificate
Career Development Certificate
Courses Only/ Non-Degree
Prior Colleges Attended: (Use additional paper if necessary.)
College/University Name: ________________________________ City: _______________________State: ________
Degree Earned: _____________________________________________________________________________________
Dates Attended: From (M/Y): ___________________________
To (M/Y): _________________________
What is your intended Major? ___________________________________________________________________________________
See list of majors online at: www.ivytech.edu
Please indicate your intent to transfer to one of the below universities and your desire to be considered for dual
admission at the identified school.
Indiana State University
Indiana University East
University of Southern Indiana
Indiana University–Purdue University Fort Wayne (IPFW)
*release of information
*The Family Educational Rights and Privacy Act of 1974 allows Ivy Tech Community College to release “directory information” (name, address, phone number, date of birth, dates of attendance, degrees received) to interested parties.
Please indicate below your preference on restricting the release of directory information to all requestors not specifically authorized under the law.
Do you give the College permission to release directory information?
Yes
No
*statement of verification
To the best of my knowledge, the information in this application is complete and accurate. When enrolled I agree to policies
and regulations of Ivy Tech Community College of Indiana, and, if offered financial assistance, to observe all regulations
required by state and federal assistance programs. I understand I am responsible for the security and confidentiality of any
personal identification number (PIN) issued to me and that it serves as my signature. I understand that the College may
communicate with me in a variety of ways, including but not limited to, email, direct mail, phone calls, and SMS text messages. I understand that if I knowingly provide false information, including but not limited to, an incorrect Social Security
Number, my enrollment may be revoked, and I may incur IRS fines and penalties. I authorize Ivy Tech Community College
of Indiana to report my academic progress between Ivy Tech campuses, to partner high schools, to other universities, and to
government entities for the purpose of research, evaluation, or transfer opportunities. I verify my citizenship status in this
application under penalties of perjury. I understand that Ivy Tech will send personal information to the email address I have
provided on the application for admission.
Signature: _________________________________________________
Date: ____________________
If you are applying for financial aid or plan to use federal educational tax credits, federal law requires that the College obtain your SSN.
* I nformation regarding gender, age, ethnic origin and citizenship status is collected for compliance reports in conjunction with federal regulations
pursuant to the Civil Rights Act of 1964, Executive Order 11246 as amended by the Executive Order 11375, and Title IX of the Education Amendments
of 1972 and Part 86.45 C.F.R., or state regulations and will not be used to discriminate in admission to or participation in any of the educational
programs or activities offered at Ivy Tech Community College of Indiana.