Application for Undergraduate Admission

Please complete the following application. Once you have completed this form, you will be directed to instructions on how to submit your $30 application fee. You will also be able to download the transcript request form, which will allow you to request official transcripts from all colleges or universities you have previously attended.

Program & Location Information

For which program are you applying?
Organizational Management
Criminal Justice Systems
Nursing for RNs
Social Work

What is your preferred location of study?

Preferred Title
Mr.	Mrs.	Ms.	Miss
Last Name	First Name	Middle Name	Former Last Name (if any)

Your Preferred First Name	If Married, Spouse's Last Name	Spouse's First Name	Spouse's Middle Name

Date of Birth	Gender	Marital Status	High School Education
	Male Female		Diploma GED
Ethnicity (optional)		Country of Citizenship

Visa Type (if you're not a U.S. citizen)

Are you a U.S. Veteran?	Veteran Type	Veteran Benefit you are eligible to receive
Yes No
Permanent Street Address		Apt. #

City		State	Zip

Mailing Address, if different from the address above		Apt. #

City		State	Zip

Name of Employer		Street Address

City		State	Zip

Home Phone Number		Cellular or Work Phone Number

Additional Phone Number		Additional Phone Number

Home E-mail Address		Work E-mail Address

High School Name	City	State	Graduation Year

You must submit official transcripts from all colleges or universities previously attended. Once you have completed this application, you will be able to download the transcript request form. This form may be duplicated as needed. In the box below, please specify the name, city and state, dates attended, and degrees earned for each college and university you have previously attended.

Have you ever been convicted of a crime (felony or misdemeanor) in any state or country?
No		Yes
Have you ever been dismissed from an institution of higher learning for academic reasons?
No		Yes
Have you ever been dismissed from an institution of higher learning for disciplinary reasons?
No		Yes

By submitting this form, I hereby certify that this application for admission information is correct and complete. I further understand that falsification or failure to supply the correct information may lead to the disqualification of my applications for admission to Keuka College. In consideration of the acceptance for enrollment at Keuka College, I guarantee the payment for all fees for tuition, and all other financial obligations incurred now, or hereafter, by the said student while in attendance at Keuka College or any Keuka sponsored program. I also guarantee the payment of any reasonable collection costs and attorneys fees incurred by Keuka in the collection of any past due balances. I will conduct myself according to the rules and regulations of the College governing student conduct.

© 2007, Keuka College • All Rights Reserved
Keuka College Center for Professional Studies
One Keuka Business Park • Penn Yan, NY 14527
adlearn@mail.keuka.edu
(866) 255-3852, toll-free
(315) 279-5407, fax

Accredited by the Middle States Association of Colleges and Schools, 3624 Market St. Philadelphia, PA 19104-2680. Phone (215) 662-5600.

National League for Nursing Accrediting Commission (NLNAC), 61 Broadway 33rd Floor, New York, NY 10006. Phone (212) 363-5555.

International Assembly for Collegiate Business Education (IACBE), P.O. Box 25217, Overland Park, KS 66225. Phone (913) 631-3009.

Commission on Social Work Education (CSWE), 1725 Duke St., Suite 500, Alexandria, VA 22314-3457. Phone (703) 683-8080.