Non-Degree Seeking and Professional Development Application

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Contact Information

Last Name

First Name

Middle Name

Maiden Name

Email

Permanent Address

City

State

Zip

County

Primary Telephone

Secondary Telephone

Personal Information

Birth Date (Month/Day/Year - MM/DD/YYYY)

Male Female
Gender

Social Security Number

We are required to collect your Social Security Number to meet federal reporting requirements and it will be securely stored. It will not be used as your student ID number.

Current Residency Status

NE Resident (how long years months)

Former NE Resident

Non-Resident

Next of Kin

Next of Kin

Next of Kin Relationship

Next of Kin Address

Telephone

City

State

Zip

Race/Ethnic Category (optional)

Compliance with Title VI of Civil Rights Act 1964 and Title IX of Education Amendments of 1972 to be used for reporting purpose only.

Without regard to your race, what is your ethnicity? If you prefer not to identify your ethnicity, select the "Decline to identify" value in the Ethnicity drop down list box.

Without regard to your ethnicity, please select one or more racial categories in the Race 1, Race 2, Race 3, Race 4, and Race 5 drop down list boxes. If you prefer not to identify your race, select the "Decline to identify" value in the Race 1 drop down list box.

Ethnicity:

Race 1:

Race 2:

Race 3:

Race 4:

Race 5:

Additional Information

Are you a US Citizen: Yes No If no, which country:
Permanent Resident

Are you a New CSC Applicant Former Student

Veteran's Benefit Yes No

YOU MUST ANSWER THE FOLLOWING QUESTION:

Have you ever been convicted of a crime involving infliction of harm by you to the person or property of others?
Yes
No

High School Information

High School Graduate Yes No

Current Year in High School or Date Graduated

Date of high school graduation (MM/DD/YYYY)

GED Date (Forward Official Scores)(MM/DD/YYYY)

Name and Address of High School

Previous College

If you attended college prior to this enrollment, check highest level completed. One category must be checked.

90+ credit hours are required before applying to take Graduate (500) Level Courses. Please note all credit hours you have taken. If you have questions pertaining to graduate level courses or to obtain Graduate Petition, contact the CSC Graduate Office at 1-800-242-3766.


0 hours	1-29 hrs	30-59 hrs	60-89 hrs	90+ hrs	BA/BS	MA/MS	Specialist	PhD

Name of Institution

Institution City

Institution State

Cr. Hrs. Earned

to
Dates of Attendance
(Start Date to End Date)

Degree

Have you ever taken a graduate course from Chadron State College?
Yes No

Admission to Chadron State College is not prohibited or limited because of age, race, gender, martial status, religion, national origin or disability.

By checking this box, I certify that all of the above statements made by me are true and complete, and that I have not omitted any relevant information. I also certify that I will inform Chadron State College of any changes in my place of residence (or if under 21, that of my parents) or other changes in the above record which occur between now and opening date of term for which I am applying.

Please view the Course Schedules and select one or two preferred courses and place the course information in the text box(s) below.

First Preferred Course

Second Preferred Course

An Academic Advisor will contact you to confirm your official schedule.

Transcripts may be requested on an individual basis for proof of prerequisite or when adding an endorsement.

Questions
Undergraduate Courses: 800-600-4099, or email elrep@csc.edu.
Graduate Courses: 800-242-3766, ext. 6214, or email kkuhnel@csc.edu.

If first-time CSC student, send $15 matriculation fee made payable to Chadron State College to:

Extended Campus Office
Chadron State College
1000 Main ST
Chadron, NE 69337

This is a valid application when submitted electronically.