Alternative Teaching Certification

Name(Required)

First Middle Last

Phone Type(Required)

Phone(Required)

Social Security Number(Required)

Date of Birth(Required)

Gender(Required)

Address(Required)

Street Address City State ZIP Code

County(Required)

Email Address(Required)

What high school did you graduate from?(Required)

Year of High School Graduation(Required)

Did you graduate from college?(Required)

College Name(Required)

Year of College Graduation(Required)

Ethnicity(Required)

African American

American Indian or Alaskan Native

Asian

White

Native Hawaiian or Other Pacific Islander

Are you Hispanic/Latino?(Required)

Are you a first generation college student (your parent(s)/guardian(s) did not attend college)?(Required)

Do you have a family member who attended or graduated from Bluefield State University?(Required)

Relationship(Required)

Year Graduated(Required)

Semester wanting to attend(Required)

Course(s) in which you wish to enroll(Required)

CRN#

Class

Your Initials for Disclosures

Signature(Required)

I declare that the information I have supplied on this application is complete, truthful, and correct and authorize BSU to verify the information given on this application.

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