Imaging Science Application

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Student Name
Last Name First Name Middle Initial

Phone

Date of Birth

Gender

Address

City/Town

State/Province

ZIP/Postal Code

County

Email Address

Concentration

What high school did you graduate from?

What high school did you graduate from?
Name of School Year

Prior College(s)

Where did you complete your 2 year degree?

Where did you complete your 2 year degree?
Name of School Degree

	Ethnicity
African American	African American
American Indian or Alaskan Native	American Indian or Alaskan Native
Asian	Asian
White	White
Native Hawaiian or Other Pacific Islander	Native Hawaiian or Other Pacific Islander

Are you Hispanic/Latino?

Yes

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

Yes

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

Yes

Relationship

Year Graduated

Disclosures

*By providing your cell phone number, you agree to receive text-based communication from Bluefield State University and from the West Virginia Higher Education Policy Commission and the West Virginia Council for Community and Technical College Education, otherwise known as the College Foundation of West Virginia (CFWV). You may also opt-out at any time by replying to any text sent.

Yes

Initial

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.

Date

Signature

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