Student ID number: 

Any information you submit is insecure and could be observed by a third party. If you are submitting information you would like to keep private, it would be safer to cancel the submission.

 Legal Name: 

Other names under which your records might be found: 
Your e-mail address(optional)

ADDRESS
Street:  City: 

State:  Zip:  Phone Number: 

Next of Kin Name: 

Next of Kin Address
Street:  City: 

State:  Zip:  Phone Number: 

Last Year of Attendance at ESU:  Major at last ESU attendance: 
If you plan to change your major, please indicate your new major: 

Semester you wish to return to ESU:  Fall 2009 Spring 2010 Summer 2010 Fall 2010

List all universities/college(s) attended since your last ESU enrollment:
Name:  Date attended:
Name:  Date attended:
Name:  Date attended:

 Are you seeking a degree from ESU: Yes No
(Must be admitted into a degree seeking program before receiving federal financial aid.)

 How many hours do you plan to enroll in for the above semester:
Special student will not be permitted to enroll in more than 6 credit hours.

 Have you lived in Kansas for the last twelve months: Yes No

 By returning this form, you certify that, to the best of your knowledge, the information furnished is complete and accurate. You MUST submit an official transcript from each institution attended since leaving ESU. Failure to comply with this could result in a fine being assessed to the student.

 Date: 
Please provide any comments you might have here. You do not have to stay within the confines of the box, you may type as long a message as you care to.