BCS/MSU CONCURRENT DEGREE PROGRAMS
UNDERGRADUATE APPLICATION FOR ADMISSION
SECTION A - PERSONAL INFORMATION
First name
Middle name
Last name
Former Surname/Family name (if applicable)
Nickname or name used (optional)
Date of Birth (mm-dd-yyyy)
Gender**:
Place of birth
Male
Marital Status:
Female
Single
Married
Engaged
Divorced
Remarried
Separated
SIN/SSN (For tuition tax receipt)
Citizenship:
Canada
United States
Other
If not a U.S. Citizen, are you a permanent resident of the U.S.?
Are you Hispanic/Latino? **
Select one or more races: **
Yes
Yes
No If yes, give alien registration number
No
American Indian, Alaska Native, or First Nations/Métis – List applicable ethnic group(s)
Asian – List applicable ethnic group(s)
Black or African American – List applicable ethnic group(s)
White – List applicable ethnic group(s)
**Disclosure of this information is voluntary. This information is requested for statistical purposes only and will not effect the status of your
application. This information will not be used in a discriminatory manner.
SECTION B - CONTACT INFORMATION
Applicants Mailing Address: Street address/PO Box
Province/State
Phone Number
City/Town
Province/State
-
-
Country
Cell Phone
-
-
Postal/Zip Code
Email Address
Single Students (Optional for applicant over the age of 18):
Mother/female guardian name:
Father/male guardian name:
Parent/Guardian street address/PO Box
Province/State
Phone Number
City/Town
Province/State
-
-
Country
Cell Phone
-
-
Postal/Zip Code
Email Address
SECTION C - ENTRANCE INFORMATION
Have you taken a course at Briercrest College before?
If yes, check here
Yes
No
If yes, when?
if you have completed more than 2 classes at Briercrest College and Seminary.
Term for which you are applying to enter:
January (yyyy)
OR
September (yyyy)
Have you previously applied for admission to Minot State University?
Yes
No
If yes, have you previously attended Minot State University?
Yes
No
If yes, when?
Please indicate BCS/MSU concurrent degree program of interest:
BA (General Studies)/BSc in Education (Elementary Education)
BA (General Studies) (Minor in Kinesiology)/BSc in Education (Physical Education)
BA (Humanities)/BSc in Education (English)
BA (Humanities)/BSc in Education (History)
BA (Music)/BSc in Education (Music)
BA (Psychology)/BS (Additions Studies)
BA (Psychology)/BS (Communication Disorders)
BA (Psychology)/Bachelor of Social Work (BSW)
I would like to an academic adviser to call
SECTION D - EDUCATION HISTORY
Last high school attended:
City
Province/State
Province/State
Graduation Date
GED (high school equivalency exam)
Completion Date
Indicate the completion date (if applicable) of the following exams: ACT (mm/yyyy)
SAT (mm/yyyy)
List all colleges, universities and schools attended, or currently enrolled, whether or not credits were earned. Include college credits
earned while in high school.
Degree(s) earned/date
NAME OF INSTITUTION
LOCATION
START YEAR END YEAR
DEGREE(S)EARNED
DATE
SECTION E – ADDITONAL REQUIRED INFORMATION
Do you now or have you lived in North Dakota?
Yes
No If yes, list years (e.g. 1990-2009)
If no, or not currently a ND resident, in what state are you a resident?
List years (e.g. 1997 – 1999
If you have lived in ND less than one year, in what state did you most recently reside?
List years
Are you the spouse or dependent of a graduate of a North Dakota public institution of higher education?
Yes
No
If yes, which institution?
Are you a Veteran of the United States Armed Services?
Yes
No
Are you a member of any of the following U.S. Armed Services?
Army
If so, are you:
Navy
Air force
Active Duty
Marines
Reservist
Coast Guard
North Dakota National Guard
National Guard
Dependent/Spouse
All students making application must answer the following questions. An affirmative response to any of these questions will not
automatically prevent admission, but you will be asked to provide additional information. The information will be reviewed by a
campus officer of committee charged with that responsibility. Falsification or omission of information may result in a denial of
admission, rescission of admission, dismissal, or other appropriate sanction.
Have you ever pled guilty (or no contest) to or been convicted of any felony?
Yes
No
Within the past 10 years have you pled guilty (or no contest) to or otherwise been convicted of a misdemeanor crime involving violence
or the threat of violence in any court? (“Crime of violence” means an offence that involves substantial risk that physical force may be
used against a person or property of another. Examples of crimes of violence include, but are not limited to, abuse, arson, assault
(including sexual assault or domestic violence), battery, breaking and entering, burglary, criminal mischief or vandalism, harassment,
homicide, menacing, reckless endangerment, stalking, terrorizing and unlawful restraint or imprisonment.
Are you currently required to register as a sex offender in any state?
Yes
No
Yes
No
Have you been dismissed or suspended from a college or university for disciplinary reasons within the last 5 years? (“Dismissed
for disciplinary reasons” means a permanent separation from an institution due to conduct or behavior. “Suspended for disciplinary
reasons” means a sanction imposed for disciplinary reasons that results in a student leaving school for affixed period but not
permanently.)
Yes
No
Go to http://www.ndus.edu/uploads/resources/1805/p-511-fbi-chbc-required--authorized-8-11.pdf to review the list of NDUS
academic programs which require further criminal history background checks. These may include nationwide FBI criminal history
background checks or a criminal history background check which may be a North Dakota BCI check, nationwide check or check of
another state or multiple jurisdictions.
SIGNATURE REQUIRED
I understand the information presented on both sides of this form will be used in evaluating my application for admission to Briercrest
College and Seminary and Minot State University. I certify that all statements are complete and true as of this date. If this information
changes, I will notify the Admission/Enrollment Services Offices of the changes and understand that my admission status will be
reevaluated at that time.
Signature of Student:
Date: