Admissions Office
MSU-Northern
P.O. Box 7751
Havre, MT 59501-7751

(406) 265-3704 or
(800) 662-6132 x3704

admissions@msun.edu

Office Location:
Cowan Hall 213

Information Request Form
Items with an * are required

Please be aware that the information you about to submit will be sent via email. If you are not comfortable sending any of this information in this manner, please call us directly at (406) 265-3704 or (800) 662-6132 x3704, and we can get the information mailed out to you.

Student Information
First Name:	*
Middle Name:
Last Name:	*
Birth Date:	*	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Contact Information
Address Line 1:	*
Address Line 2:
City:	*
State/Province (US/Canada):	*	Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick Newfoundland and Labrador New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
Country: (if not US)
Zip/Postal Code:	*
E-mail:	*
Phone (Cell):	*	( ) -
Phone (Home):		( ) -
Contact Preference:		Email Text Phone

Academic History
High School:	*		Graduation Year:
Prior College:

Admisson
Term Attending:	*	Fall Spring Summer	*	Year Attending: 2012 2013 2014 2015
Major:	*

Please send me the following information:
	Application	Campus Visit	Academic Guide
	Fee Sheet	Financial Aid	WUE/Non-resident
	Scholarships	Housing-Student	Housing-Family
	Other:

How did you hear about MSU-Northern?
	High School Visit	College Fair	Website
	Friend	Parent	Counselor
	Other:
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