Center at Scott AFB Application

Please fill out the following application form for the Center at Scott AFB.

    

Your Information
 
First Name    Middle Name    Last Name    Suffix
     

Maiden/Previous Names
Name by which you are called (nickname)
 
Social Security Number
 
 
Permanent Home Address
 
Street Address
Address Line 2
 
City
State/Province/Region
 
Postal/Zip Code
Country
 
County
 
 
Mailing Address (If different from above)
 
Street Address
Address Line 2
 
City
State/Province/Region
 
Postal/Zip Code
Country
 
County
 
 
Daytime Phone (xxx-xxx-xxxx):
 
 
Evening Phone (xxx-xxx-xxxx):
 
 
Home E-mail address:
 
 
Work E-mail address:
 
 
Date of Birth (MM/DD/YYYY):
 
 
Gender
 
 
Are You a U.S. citizen?
 
 
If no, specify your status below:
 
Non-Resident Alien
 
 
 
Resident Alien
 
 
 
 
 
 
If yes, please specify below.
 
 
Branch
Rank
 
Are you in the:
 
 
Reserves          
 
 
Guard
 
 
Are you:
 
Military Dependent
 
 
Base Civilian
 
 
Community Civilian
 
 
Veteran
 
 
When do you wish to begin classes at McKendree?
 
 
Status of enrollment:
 
Full-Time
 
 
Part-Time
 
 
Returning Student
 
 
Degree Seeking
 
 
Non-Degree Seeking
 
 
Anticipated College Major:
 
 
If multiple majors, please state each.
 
Do you need a pass for base entry?
Do you plan to apply for financial aid?
 
High School attended name:
 
 
City
State
 
Year graduated or GED completed:
 
 
Specify below:
 
 
 
 
 
 
 
 
 
Are you Hispanic or Latino?
 
 
 
What is your race?
 
American Indian or Alaska Native
 
 
Asian
 
 
Black or African American
 
 
Native Hawaiian or Other Pacific Islander
 
 
White
 
 
Check all that apply.
 
American Indian or Alaska Native
 
Asian
 
Black or African American
 
Native Hawaiian or Other Pacific Islander
 
White
 
Religious background/denomination:
 
 
How do you plan to pay for college?
 
Military Tuition Assistance
 
 
VA Educational Benefits
 
 
VA Rehabilitation
 
 
Reserves/Chapter 106
 
 
Company Reimbursement
 
 
Pell Grant
 
 
ISAC Grant
 
 
Loan
 
 
Self Payment
 
 
Check all that apply.
 
 
 
 
Applicant's Affidavit
 
Statement of Understanding
 
Applicant's Initials
Date: