Office of Admissions Post Office Box1430 Tuscaloosa, Alabama 35403-9990 (205) 366-8817 • (800) 841-5722 www.stillman.edu
Social Security Number
Title *
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Mr
Mrs
Miss
Marital Status
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Single
Married
Companion
Divored
Widowed
Separated
Correction
Last Name
First Name
Middle
Current Mailing Address
Apt
City
State
Zipcode
County
Are you a U.S. Citizenship
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Yes
No
Select Country of Citizenship
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Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombi
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
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Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
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Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepa
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Home Telephone Number
Cell Telephone Number
Date of Birth
E-mail Address
College Plans
Intended Semester of Enrollment
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Spring 2013
Summer 2013
Fall 2013
Spring 2014
Summer 2014
Fall 2014
Intended Load
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Less than Half Time
Full Time
Overload
Half Time
Part Time
Intended Major
Education Goal
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Baccalaureate
Career Goal
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Business Administration
Health & Physical Education
Teacher Education
General Education
Pre-Law
Pre-Med
Stillman Management Inst
English
Biology
Religion & Philosophy
Social Science
Math
Computer Science
Incoming Student Status
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New Freshman
Returning
High School Dual Enrollment
Transfer
Transient
Have you or will you apply for Financial Aid?
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Yes
No
Would you like to receive information about Campus Housing?
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Yes
No
Academic History
Status
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High School Graduation (or Candidate
G.E.D Graduate
High School Name
Graduation Date:
List all colleges and universities attended (including Stillman) in which you have been enrolled for course credit. Official transcripts from each college and/or university you have attended MUST be forwarded to the Office of Admissions.
List the Name of the School City/State and Dates Attended
Parent/Gardian Information
First Name
Last Name
Relationship
Mailing Address
City
State
Zip Code
County
Home Telephone Number
Cell Phone Number
E-mail Address
Extracurricular Activites
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Art
Band
Basketball
Baseball
Cheerleading
Choral Singing
Dance
Drama Club
Football
Honor Society
Modeling
Photography
SGA
Tennis
Track and Field
Volleyball
How Did You Learn Of Us
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Stillman Alumnus
College Representative
Newspaper/Magazine
Radio
College Tour
Counselor/Teacher
Family Member
Friend
College Fair
Mail Correspondence
Contact Person
List below the complete names, addresses, and telephone numbers of persons (not residing with you) who will always know your address.
General Disclosure
Have you ever been expelled or suspended for academic or disciplinary reasons from a school or college/university?
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Yes
No
If you answer YES to the following question, please give a brief explanation below.
Have you ever been convicted of any criminal offense other than a traffic violation?
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Yes
No
If you answer YES to the following question, please give a brief explanation below.
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