Kentucky MSN Application

Please fill out the application for the MSN program.

    

Your Information
 
First Name    Middle Name    Last Name    Suffix
     
E-mail

Maiden Name
Preferred Name
 
Social Security Number
Gender
 
Date Of Birth (mm/dd/yyyy)
 
 
 
 

 
Address
 
Street Address
Address Line 2
 
City
State / Province / Region
 
Postal / Zip Code
Country
 
County
 
 
Home Phone
 
 
Cell Phone
 
 
Work Phone
 
 
Emergency Contacts
 
Primary Contact
 
Last Name
First Name
 
Relation
If "Other", please specify:
 
Street Address
Address Line 2
 
City
State
 
County
Postal / Zip Code
 
Home Phone Number
Cell Phone Number
 
Preferred Email
 
 
Secondary Contact (Optional)
 
Last Name
First Name
 
Relation
If "Other", please specify:
 
Street Address
Address Line 2
 
City
State
 
County
Postal / Zip Code
 
Home Phone Number
Cell Phone Number
 
Preferred Email
 
 

 
Are you applying as an international student?
 
 
Have you ever been convicted of a felony?
 
 
 
 
Program
 
 
Location
 
 
 
 
 
Example:
 
 
 
 
 
 
 
 
 
 
 
 
Example: John Doe, Uncle, 1996
 
 
 
 
Are you a veteran?
 
 
 
Friend
 
Professor
 
Graduate Fair
 
Employer
 
Mailing from McKendree
 
McKendree Website
 
Facebook
 
Other
 

 
 
Are you a United States citizen?
 
 
If you chose no, please describe your status
 
 
 
 
Are you Hispanic or Latino?
 
 
 
 
American Indian or Alaska Native
 
Asian
 
Black or African American
 
Native Hawaiian or Other Pacific Islander
 
White
 
American Indian or Alaska Native
 
Asian
 
Black or African American
 
Native Hawaiian or Other Pacific Islander
 
White
 
Religious Background/Denomination
 
 
APPLICANT'S AFFIDAVIT
 
Date (mm/dd/yyyy)
Initials