College of Lifelong Learning

Application for Admission into the Bachelor of Science in
Professional Interdisciplinary Studies (PrIS) Degree Program - Form IV

 

1:

Social Security Number:  - -  
3.
Street Address                                                                                        Apt.#
City State
Zip
4: Contact Number:

5.
Email:
6. Sex:
7.

Race   :
Race: Race:  
Race: Race:        

8.
Age:
9.

   

10.
Date of Birth:  
11. Number of children living at home:
12. Date of entry or enrollment at Jackson State University:  
13. Classification:
14.


15.

   

16. Have you taken the English Proficiency Examination?:         When?


17. If you have taken the English Proficiency Exam, did you pass the examination?
18. Are you changing your major? , If yes, from to
19. Were you referred to this program?    If yes, by whom: