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Complete this form if you wish to return to classes and have not attended Zane State College for the past one or more semesters (not including summer session). This form should be completed only by individuals who have received grades from Zane State College.

Student Information

Social Security Number or Student ID:
Date of Birth (mm/dd/yyyy):
If male, aged 18 to 26, please provide your Selective Service Number.
To look up your # go to SSS.gov
Current Name (Last, First, Middle):
Maiden/Previous Name(s):
Contact Number:
Personal Email Address:
Current Address
Number & Street:
Apt. #:
City:
State:
ZIP Code:
Country:
Returning Information
Planned Semester of Return/Year:
Planned Program of Study:
Do you plan to receive a(n):
Associate Degree Certificate Non-degree Seeking Transient
Have you resided in Ohio for the immediate past 12 months?
Yes No If no, previous state:

Demographic Information

Your response is voluntary. Information will not be used in a discriminatory manner and will remain confidential as to the individual, but may be used in general submission data.

Are you Hispanic?
Yes No
Are you a Nonresident Alien?
Yes No
Please select one or more of the following categories to describe yourself:
American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

Previous Education

Are you a graduate of Zane State College? Yes No
If yes, what year? Program?
List all colleges attended with the most recent first. Attach extra sheet if needed (submit official transcripts from each college):
Name of College City/State

Emergency Contact Information

In the event of emergency, notify:
Last Name First Name Telephone

Release of Information

Zane State College has permission to release my name, address, telephone listing, college major, dates of attendance, degrees and awards received (including dean’s list) and most recent previous education agency or institution attended to news media or other appropriate agencies.
Yes No
Initial to acknowledge:
I hereby certify that all statements on this form are correct and understand that I may be required to provide documentation at some future date to substantiate my claim and that any misrepresentation of this data may result in the cancellation of my enrollment or registration status and is considered a breach of academic honesty.
Agree Disagree
Please use the following format when signing*: /John Q. Smith/
Signature: Date:

*Please see the following website for Consent for Use of Electronic Signature:
Consent for Use of Electronic Signature