1. Active Military: ; Branch of Service 5. Are you on academic probation at another school? Yes _____ No _____
2. Veteran: ; Branch of Service 6. Are you on academic suspension at another school? Yes _____ No _____
3. Military Dependent: ; Is Service Member Active?
4. In what state is the active duty member stationed?
First Name Middle Name Last Name Other Name(s) under which your records may appear
THE FOLLOWING OFFICIAL DOCUMENTS ARE REQUIRED FOR
ADMISSION. ANY EXCEPTIONS MUST HAVE THE REGISTRAR’S
APPROVAL.
1. Completed Application for Admission Form
2. High School and/or college Transcript(s), or G.E.D. certificate and
Scores.
3. Results from ONE of the following: ACT, SAT, or RSC
Assessment Battery may be required.
1. Please Print or Type
2. Use Black or Blue Pen
3. Do not Write in Shaded Areas
4. Abbreviate Where Necessary
ALL INFORMATION MUST BE COMPLETED
ROSE STATE COLLEGE
Office of Admissions and Records
6420 S.E. 15th Street
Midwest City, OK 73110
Sex
_____
Male _____
Female
MO DAY YEAR City State Country (if not U.S.)
Date of Birth Place of Birth
Prefix: Mr. _______
Ms. _______
Social Security Number
Resident Status: STUDENT’S E-MAIL ADDRESS
1. Resident of Oklahoma?
How Long? _______ Years _______ Mos.
2. U.S. Resident?
Visa Type: F-1 ____ J ____ H ____ Other _______
3. Resident Alien?
A# ________________________________________
To Be answered by U.S. and Foreign Students:
4. English is my second language? Yes ____ No ____
Official documents required by the U.S. Citizenship and
Immigration Service, Oklahoma State Regents,and Rose
State College must be received and evaluated before an
I-20 will be issued.
Employer ______________________________________
Work Phone ____________________________________
Term Entering: Classification:
FALL ________________ _____ Freshman
SPRING _____________ _____ Sophomore
SUMMER ____________ _____ Special
First Name Last Name City State/Country Zip Code
--
PARENT OR EMERGENCY CONTACT
Number and Street AC Telephone
State County Zip Code
STUDENT’S CURRENT ADDRESS
Number and Street City
--
AC Telephone
Student ID Number
Former RSC Student? ______ Yes ______ No
Admissions Use Only aplication for admision
The following information is optional but is requested for reporting purposes
only in accordance with the 1964 Civil Rights Act, Title VI, as amended.
Do you consider yourself Hispanic or Latino?
Select one or more of the following categories to describe you.
1. _____ Non-Resident Alien
2. _____ Black or African American
3. _____ American Indian
or Alaskan Native
Tribe______________________________ Blood Line: ____ Mother
____ Father
____ Both
4. _____ Asian
5. _____ White
6. _____ Native Hawaiian
or Pacific Islander
Yes No
Yes No
Yes No Yes No
Yes No
Yes No
Yes No
Yes No
*
1.
2.
3.
4.
5.
6.
7.
I hereby affirm that all information supplied on this form is complete and accurate. It is my understanding that I shall not be considered for admission to Rose State College until I submit all required documents. If
I am accepted at Rose State College, I agree to abide by the rules and regulations of the College. I also understand that student records are released only in accordance with institutional policy as provided by the
Family Educational Rights and Privacy Act (as amended).
Applicant’s Signature _______________________________________________________________________________________________ Date __________________________________________
TRANSFER STUDENT INFORMATION
Please list all colleges attended since graduation from high school, including current enrollment. List most recent college attended first. Failure to list any
colleges you have attended may result in loss of credit or dismissal from the College.
Name of Institution City & State
Date
Attended
From To
Hours
Earned
PS CODE
(For Official Use Only)
Disclaimer Statement
Name of Last High School Attended
High Schol GraduatE : ____ Yes ________ YEAR
____ No
GED: ____ Yes __________ YEAR
____ No
City State
for oficial use only
County Code Resident Admissions Use
Code
Admit Code PS High School Code PS CODE
(Last College Attended)
Month Day Year
Rose State College, in compliance with Titles VI and VII of the Civil Rights Act of 1964, as amended,Title XI of the Education Amendments of 1972, Americans with Disabilities Act (ADA) of 1990 and other
federal laws and regulations, does not discriminate on the basis of race, color, sex, age, national origin, religion, disability, sexual orientation or status as a veteran in any of its policies, practices, or procedures.
This includes, but is not limited to, admissions, employment, financial aid, and educational services. Issues of noncompliance should be referred to the Affirmative Action officer, Administration Building, Room
104; telephone (405) 733-7979 or TDD (405) 733-7355. Rose State College is accredited by The Higher Learning Commission: A Commission of the North Central Association of Colleges and Schools.
DOCUMENTATION OF
STUDENT VACCINATION STATUS
Rose State College is committed to protecting the health of its students. Therefore, the
submission of the following information is being required of all new students who will be
attending classes on-campus.
Please check one of the following:
I hereby certify that I have received the vaccinations for measles, mumps, rubella
and hepatitis B.
I hereby certify that I have received vaccinations for measles, mumps and rubella
and will complete vaccinations for hepatitis B within 6 months.
I hereby certify that the administration of the vaccines for measles, mumps,
rubella and hepatitis B conflict with my moral or religious tenets. (In the case of
a minor, this must be certified by a parent or legal guardian.)
I am submitting below a physician’s statement indicating it is medically
inadvisable for me to take these vaccinations.
I belong to one of the groups of students listed under the Exemptions portion of
this form, and have identified the group to which I belong.
The information provided in this document is true and accurate to the best of my
ability. I understand that falsification of this document is a violation of the Student
Conduct code and such conduct could result in suspension or expulsion from Rose
State College.
________________________________ ________________________________
Student Name Student ID#
________________________________________ __________________
Signature of Student, parent, or legal guardian Date
PHYSICIAN’S STATEMENT
I hereby certify that the administration of the vaccines for measles, mumps, rubella and
hepatitis B are medically inadvisable for the above named student.
_________________________________________ __________________
Signature of Licensed Physician Date
EXEMPTIONS
Certain groups of students will not be asked to provide vaccination information. Please
indicate if you belong to any of the following groups.
I am a high school graduate and that I graduated from an Oklahoma high school
since 1996.
I am transferring from another college located in the State of Oklahoma.
I am only enrolling in off campus or distance education courses.
I am active military.
I am enrolling in Training Center classes only.
I graduated from a high school that required these vaccinations. State of high
school graduation: _____________________Year of Graduation _____________
I have been provisionally admitted and will take no more that 9 credit hours at
this institution until I have submitted the above information and been admitted as
a regular student.
If my status at this institution changes so that the above claimed exemption no
longer exists, I understand it is my responsibility to notify the institution of these
changes and to provide my vaccination information before I enroll in additional
course.
____________________________________ ____________________
Student Signature Date
Return the completed form to:
Rose State College
Office of Admissions and Records
6420 S.E. 15th Street
Midwest City, OK 73110
Please return the completed form to:
Rose State College
Office of Admissions and Records
6420 S.E. 15th Street
Midwest city, OK 73110 ROSE STATE COLLEGE
TO THE PROSPECTIVE STUDENT: In order to complete the transfer to Rose State College, you
must have this form completed by the last institution you were authorized by the United States
Citizenship and Immigration Service (USCIS) to attend.
I, give permission for my current institution to
(PRINT NAME CLEARLY: Last, First, Middle, Maiden)
release the following information.
Signature of Student
********************************************************************************************************
TO THE INTERNATIONAL ADVISOR: Please complete the following information for the above
student and return to the above address.
Student’s Visa Type: INS I-94 Number:
SEVISNumber:
First semester/quarter/session (circle one) in attendance at your school:
Last semester/quarter/session (circle one) in attendance at your school:
Currently or last enrolled in semester/quarter (circle one) credit hours.
Is student in good academic standing? Yes No, Reason:
Is student in good financial standing? Yes No, Reason:
Has student ever applied for reinstatement of status? No Yes; When?
Has student been granted off-campus or practical training employment? No Yes
If yes, briefly explain:
Has the student been the subject of disciplinary action while in your school? No Yes
If yes, briefly explain:
Signature Nameand Titleof Official Date
Institution Name and Address E-mail Address
(INSTITUTIONAL SEAL)
ROSE STATE COLLEGE
6420 S. E. 15th Street
Midwest City, Oklahoma 73110-2799
INTERNATIONAL STUDENT CERTIFICATE OF SUPPORT
Listed below are the estimated expenses for International Students attending the Fall and Spring semesters (based on 12 credit hours each
semester). Costs for the summer are not included in this estimate. You should plan on having extra funds available for travel back to your
country or to stay in the United States during the summer months. Please understand that tuition costs are estimated and subject to change by
the Oklahoma State Regents for Higher Education.
Direct Educational Costs:
Tuition and Fees ............................................................................................................................... $4,900.00
Books and Supplies ............................................................................................................................... 800.00
Other Living Costs
Housing and Utilities ........................................................................................................................ $5,900.00
Personal Expenses .............................................................................................................................. 1,900.00
Transportation .................................................................................................................................... 1,000.00
Health and Repatriation Insurance......................................................................................................... 500.00
TOTAL COSTS .............................................................................................................................$15,000.00
* Rose State College does not have on-campus housing. Students rent apartments within the Midwest
City area or in nearby Oklahoma City. Location of a student’s housing may affect transportation costs.
* All international students are required to purchase and maintain Health and Repatriation Insurance. The
cost will be determined by the insurance company and policy plan the student chooses. Information is
available in the International Admissions Office.
The next portion of this form must be completed and returned to Rose State College with your completed application for admission along
with any other documents that may be required.
A CERTIFIED BANK STATEMENT OR LETTER FROM YOUR SPONSOR’S BANK SHOWING AVAILABLE FUNDS TO COVER EXPENSES FOR ONE YEAR
FOR THIS STUDENT MUST BE ATTACHED AND MUST INCLUDE A TRANSLATION TO U. S. DOLLAR EQUIVALENCY. THE DOCUMENTATION MUST
BE A CURRENT ORIGINAL NO MORE THAN 90 DAYS OLD. THE SPONSOR NAME ON THIS CERTIFICATE OF SUPPORT MUST MATCH THE SPONSOR
NAME ON THE BANK STATEMENT OR LETTER .
NOTE: SELF-SPONSORSHIP IS NOT ACCEPTABLE. A SPONSOR CANNOT BE ANOTHER
INTERNATIONAL STUDENT
SPONSOR’S VERIFICATION OF SUPPORT
This certifies that I, _________________________________________________________________, will assume full responsibility for the
SPONSOR’S PRINTED NAME
Financial support of ____________________________________________ during his/her studies at Rose State College.
STUDENTNAME
______________________________________ ______________
SEAL OR STAMP
CERTIFICATION
Sponsor’s Signature Date
SPONSOR’S RELATIONSHIP TO STUDENT:________________________________
SPONSOR’S ADDRESS:____________________________________________________
I certify that the above mentioned person is financially capable of providing the funds necessary for attendance at Rose State College. This does not include finances for the care
of a spouse or children.
________________________ ____________________________________________________
DATE SIGNATURE & TITLE OFBANK OR GOVERNMENT OFFICIAL
Sample Bank Letter
(Must be printed on official bank letterhead paper, and have an original bank
official’s signature and the bank’s official stamp or seal on the letter)
Date of letter
(Must have been printed within the past 90 days)
(Sponsor’s name), (relation to student) of (student’s name), is an account holder in
good standing at (Name of Bank). According to our institution’s records, he/she is
capable of supplying funds to pay for all of (student’s name)’s educational and living
expenses while he/she is an enrolled student at Rose State College.
This letter should serve as verification from our institution that (sponsor’s name) has a
(type of account) containing available funds totaling (local currency). This amount is
equal to (the equivalent amount in U.S. dollars) in U.S. currency.
I certify that the information contained in this letter is true and correct.
Sincerely,
Signature of Bank Official (Bank’s Official Stamp or Seal here)
Name and Title of Bank Official
