Jenzabar University

Personal Information

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First Name (Surname)

Last Name (Given Name)

Preferred First Name (Nickname)

Gender

Birth Date

Marital Status:

Spouse's First Name

Spouse's Last Name

Country of Present Citizenship

Citizen Of

U.S. Citizenship Status

If you selected US Permanent Resident, please enter number:

In what city were you born?

In what country were you born?

Ethnicity/Racial Background

The U.S. Department of Education has issued new guidelines for how institutions will collect and report race and ethnicity data.  In order to respond to this request, we ask you to please respond to the following questions.

Race (Choose one or more)

Ethnicity

Additional Information

SSN

Religion:

Have you ever been convicted of a felony?

If yes, please explain the circumstances of your felony conviction.

Candidacy Information

Anticipated Academic Enroll Year

(Each year goes from August - July)

Anticipated Academic Enroll Term (Fall term is August - December, Spring term is January to early May, Summer term is May-June)

Name the first Course you want to take

Name of first Course you want to take:

Would you like to Audit this course or take it for Credit?

Name the second Course you want to take

Name of second Course you want to take:

Would you like to Audit this course or take it for Credit?

Name the third Course you want to take

Name of third Course you want to take:

Would you like to Audit this course or take it for Credit?

Other College/University where I am currently enrolled:

Contact Information

Permanent Home Mailing Address:

Do you reside outside of the United States?

Address Line 1

Address Line 2

City

State/Province/Prefecture

State

Zip/Postal Code

County of Residence (if state is Kansas):

Country

Primary Phone Number

Your Email Address:

Parent Information

Do you reside with your father?

Did your father attend Hesston College?

Father First/Given Name

Father Last Name (Surname)

Father Education Level

Father Primary Phone Number

Father Email Address:

Do you reside with your mother?

Did your mother attend Hesston College?

Mother First/Given Name

Mother Last Name (Surname)

Mother Education Level

Mother Primary Phone Number

Mother Email Address:

High School and College Information

Do you have a GED?

Name of Institution

City of Institution

State of Institution

High School or College/University?

High School Graduation Date:

High School GPA: