CHECK APPROPRIATE APPLICATION:
 
Freshman Transfer Transient
 
Teacher Certification Re-Admit Audit
1.
Social Security Number:   -   -  
2.
Name:      
  First Middle Last
3.
Gender: Male Female
         
4.
Beginning Semester:
Fall Spring Summer, 20  
             
5.
Prospective Major:
   
6.
Date of Birth:
  Mo. Day Yr
       
7.
Place of Birth:
   
8. Address:          
    Street Apartment # City State Zip Code
             
9.
County:
   
10.
Area Code:   Phone:  
       
11.
Name of High School:
Location:
   
12.
Month/Year of Graduation/
Expected Graduation:  
   
13.
Have you taken the
ACT/SAT Exam?		 Yes No
13(a).
If Yes, date taken:
   
14.
If you did not graduate,
did you pass the
“GED” Test?		 Yes No
14(a).
Composite Score:
   
15.
LIST ALL COLLEGES ATTENDED, NCLUDING MILES:
Institution/
Location		 Dates of Attendance Reason for Withdrawal
16.
Did your parent(s) attend Miles?
  Yes No
         
  16(a).
If yes, name of Parent:
 
   
17.
Do you plan to apply for Financial Aid? Yes No
17(a).
Are you a legal resident of Alabama? Yes No
18.
Have you ever been suspended, placed on probation, or denied enrollment by an Instituiton, including MILES?
 
Yes No 18(a). If yes, explain:  
             
19.
Have you ever been arrested or convicted of a misdemeanor or felony?
 
Yes No 19(a). If yes, explain:  
             
20.
Do you need special accommodations upon enrollment at the College?
 
Yes No      
If yes, please contact, prior to the application deadline: Miles College ADA Compliance Officer
• 5500 Myron Massey Boulevard • Fairfield, AL 35064 • (205) 929-1447
 
21.   Person to notify in case of Emergency: Name:   Relationship:  
           
 
Address:          
 
Street
Apt #
City
State
Zip Code
           
 
Telepone Home: ( )   Work : ( )  
 
22.
I certify that the above information is true, accurate and complete:
 
Applicant’s Signature: ( )   Date : ( )