Year 20_____
( ) Fall
( ) Spring
Records, Admissions,
& Registrar’s Office
P.O. Box 67
Tsaile, AZ 86556
(928) 724-6630, 6631
Fax: (928) 724-3349
( ) S.S.I
( ) S.S.II
( ) 10 wks
CAMPUS APPLYING TO:
( ) Tsaile Campus
( ) Shiprock Campus
( ) Center/Campus Site
_________________
APPLICATION FOR ADMISSION
One time $20 Application Fee for New students (NON-refundable)
SOCIAL SECURITY NUMBER
LAST NAME
FIRST NAME
STUDENT CARS ID#
PERMANENT MAILING ADDRESS
BIRTHDATE
Name & location of High School Attended
Received GED?
IF RECEIVED GED, DATE & STATE
SEX:
VETERAN:
MAIDEN NAME
Date Graduated from High School
CENSUS/ ROLL No.
If yes,
ENROLLED AGENCY
TELEPHONE NUMBER
FEMALE
YES
Active
Work (
)
_________(optional)
MALE
NO
Retired
Home (
)
_________
PREDOMINANT ETHNIC BACKGROUND:
American Indian / Alaskan Native
Tribe:
Caucasian (Non-Hispanic)
Black (Non-Hispanic)
Hispanic (Mexican-American)
Asian/Pacific Islander
Other, Please Specify
_____________
DO YOU HAVE DISABILITY?
MARITAL STATUS:
Single
Married
Separated
Divorced
Hearing
NO
Speech
Mobility
IF FOREIGN, INDICATE COUNTRY
HIGHEST GRADE
COMPLETED:
8 9 10 11 12
13 14 15 16 +
CHAPTER AFFILIATION
Email:
TYPE OF DISABILITY?
YES
STATE OF RESIDENCE
Widowed
Learning Disability
UNITED STATES CITIZEN
YES
NO
Vision
ALIEN REGISTRATION NUMBER
COUNTY OF RESIDENCE
VISA TYPE
WANT TO STAY IN THE DORMITORY?
(Tsaile Campus Only)
YES
NO
ADMISSION STATUS:
DEGREE SEEKING
New – Never Attended NCC/Diné College
YES
________________________
Readmission – After Absence
(PROPOSED MAJOR)
Continuing – From Previous Semester
NO
Transfer – From Another College/University
Graduate, has BA, MA, or PhD degree
Special/Visitor
LIST ALL COLLEGES, UNIVERSITIES & TECHNICAL SCHOOLS ATTENDED IN ANY STATUS
Name of Institution
City & State
From
To
Degree Received
IN THE EVENT OF AN EMERGENCY, PLEASE NOTIFY:
ADDRESS
_______ _______________________________________ ___
TELEPHONE
RELATIONSHIP
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
__________________________________
DATE
Diné College on the Web: http://www.dinecollege.edu
_________________________________________________
APPLICANT’S SIGNATURE