Fort Hays State University

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Application for Admission to Graduate School
Fort Hays State University
Hays, Kansas 67601-4099

Items with an asterisk are for reporting to Federal Compliance Agencies only and will not be used in determining admission status.

Last Name:

First Name:

Middle Name:

Maiden Name:

Give any other names under which you have previously enrolled at FHSU or at any other college or university:

E-mail Address:

Mailing Address:

Address:

City:

County:

State:

Zip Code:

Telephone No.:

Social Security Number:

City Of Birth:

State Of Birth:

Date Of Birth:

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Gender*:

Male
Female

Program of Study (Major):

Non-Degree Seeking

Certificate or Endorsement:

Semester you wish to enroll:

Give the names, addresses and dates of all colleges and universities attended, including FHSU:

Institution	Location	Dates Attended	Major	Degree & Date

List two most recent positions held:

Nature of Position	Company or Institution	Location	Inclusive Dates

*To comply with the Civil Rights Act of 1964 and Title IX Education Amendments of 1972, please check one of the following categories. Responses from individuals will be confidential.
	Asian or Pacific Islander: Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, and Samoa.
	American Indian or Alaskan Native: Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition.
	Black (not of Hispanic origin): Persons having origins in any of the Black Racial groups.
	Hispanic: Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish Culture or origin, regardless of race.
	White (not of Hispanic origin): Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.

Have you lived in Kansas continuously for the past 12 months? :

Yes
No

Check one box:

American Citizen
Perm. Resident Alien

I fall within the definition of disabled. (A disability which substantially limits one or more major life activities)(OPTIONAL):

Yes
No

I would like information on campus services for the disabled:

Yes
No

Submission of this application form is the first step in applying to Graduate School. Other requirements are listed under Programs and Degrees. All materials should be sent directly to the Graduate School. Thank you!