Undergraduate Badge Application

First Name

Middle Name

Last Name

Alternate Last Name

Birthdate

Cell Phone

Email Address

Sex Assigned at Birth

Social Security Number

Mailing Address

Country

Street

City

Region

Postal Code

Citizenship Information

Primary Citizenship

Residency Status

Permanent Resident

What visa status do you currently hold?

Ethnicity (Optional)

If you wish to be identified with a particular ethnic group, please select the choice that most accurately describes your heritage. No information you provide will be used in a discriminatory manner.

Are you Hispanic or Latino?

Please select one or more of the following races:

Kansas Residency

Are you a resident of the state of Kansas?

Yes

No

Have you lived in Kansas since birth?

Yes

No

When did you begin living continuously in Kansas?

If you relocated to Kansas, from which state/province did you move?

Have you previously lived in Kansas?

Yes

No

Start Date

End Date

Last year, did anyone claim you as a dependent for income tax purposes?

Yes

No

Is either of your parents or your guardian a Kansas resident?

Yes

No

How long has he or she been a Kansas resident?

Years

Months

Which best currently describes you?

Do you have a Bachelor's degree?

Yes

No

I certify the following:

That the information on this application is complete and correct, and that false information is grounds for denial of application, cancellation of enrollment or any appropriate disciplinary action.

As a WSU student you will receive a Wichita State University related email address. It is your responsibility to access and monitor this email for university related communications. Once your admission is complete you will receive additional instructions on how to establish and access your WSU email account.

I understand that it is my responsibility to access the course information to complete the course.

Signature: Please sign (type) your name indicating that you understand the above.