Section I: Personal Information

First Name *	Middle Name *	Last Name *

Date of Birth *	Former/Maiden Name	Preferred Name

Street Address *	City *	State *	Zip Code *

Home Phone *	Business Phone	Cell Phone

Social Security Number *	Email Address *	County of Residence *

How long have you lived at your current address?

Previous Address	City	State	Zip Code

Providing the following information is optional, and will in no way affect your application status. Check here if you are choosing not to answer these questions:   Are you Hispanic/Latino? Yes No Are you a citizen of the United States? Yes No Gender: Male Female Race:     Choose One American Indian or Alaskan Native Asian African-American Pacific Islander Caucasian Non-Resident Alien

Section II: Enrollment Information

Desired Start Term: *

Choose One Augmester Fall Winter (Online) Spring Maymester Summer

Desired Start Year: *

I wish to: *

Choose One Earn an Associate of Arts or Associate of Science Degree Earn an Associate of Applied Science Degree Earn a Certificate Non-Degree Seeking: Earn credit for transfer to another college Non-Degree Seeking: Upgrade job skills Non-Degree Seeking: Taking classes for personal interest

Section III: Student Status Information

I will be a: *

Choose One First Time Student Returning Three Rivers Student Transfer Student Visiting Student Dually Enrolled Student Dual-Credit Student Unclassified Special

Are you a resident of the Three Rivers College District? * Yes No

(Butler, Carter, Wayne or Ripey counties in Missouri)

Has either parent earned a Bachelor's degree? * Yes No

Do you plan to apply for financial assistance? * Yes No

Do you plan to apply for veteran's benefits? * Yes No

Marital Status: Married Single

Do you live: With Parents Away from Parents

Will you attend Three Rivers: * Full-Time Part-Time

Section IV: High School Information

High School Name *	City *	State *

Answer one of the following: *

Graduated (Year)	GED Earned (Year)	Will Graduate (Year)	Plan to take GED (Month/Year)

Have you taken the ACT Exam? * Yes No        Date:  

Section V: Colleges & Universities

Applicants MUST list all institutions of high education. Submission of official transcripts is recommended prior to registration. *

School Name	Degree	Dates Attended

School Name	Degree	Dates Attended

School Name	Degree	Dates Attended

Total number of semester hours of college credit accumulated:  

Are you on academic suspension from any college or university? Yes No

Have you ever been disciplined at a college or university? Yes No

If you answered "Yes" to either of the above questions, please explain:

Section VI: Criminal Background

Have you ever been arrested for, charged with, pleaded guilty, or been convicted of a felony? * Yes No

Federal law requires sex offenders already required to register in a state to provide notice to each institution of higher education in that state at which the person is employed, carries a vocation, or is a student.

Are you required by law to notify this institution of higher education of your sex offender status? * Yes No

If you answered "Yes" to either of the above questions, please explain:

Section VII: Admissions Policy

Three Rivers has an open-door admissions policy; welcoming applications for admission from any person who has a high school diploma, its equivalent, or is 18 years of age, and is able to benefit from a program may be admitted to Three Rivers as a curricular or non-curricular student. Three Rivers is an equal opportunity affirmative action institution and does not discriminate against any student on the basis of race, color, sex, religion, age, disability, national origin, or legal political affiliation or membership. The College evaluates special cases for acceptance.

Pursuant to Missouri State Statute 174.130, Three Rivers will not knowingly admit any aliens unlawfully present in the United States. Proof of legal residency may be required at the time of application.

Do you have a physical or mental impairment that substantially limits one or more major life activities, (ie, seeing, hearing, speaking, walking, learning, working)? Yes No

Persons with a disability could qualify for accommodations and should contact the Student Success division for services available.

Section VIII: Computer Network/Internet Acceptable Use Policy

Three Rivers requires that all students, faculty and staff fully comply with the Computer Network and Internet Acceptable Use Policy regarding their use of college computer equipment, local and wide-area networks and Internet services. A copy of the complete policy can be found here. By signing this admission application, you agree to comply with the terms of this policy and agree to review this policy each semester and agree with any changes or revisions.

  By checking this box I agree to comply with the Acceptable Use Policy. *

Section IX: Submission

I understand that Three Rivers will release my enrollment information to the National Student Clearinghouse and federal and state agencies.

I hereby certify that, to the best of my knowledge, the preceding information is true and complete without evasion or misrepresentation. I understand that if it is later found to be otherwise, it is sufficient cause for rejection or dismissal.

  By checking this box I verify that I have read and agree to the above statements. *