Complete all three sections, sign and return to the above address.

1. -----------------------------------------------------------------------------------------------------------
Applicant__________________________________________________________________________
                                Last Name/Family Name                                               First Name                                     Middle Name (Initial)
Mailing Address:_____________________________________________________________________
                                                   Number & Street                                                        City / State/ Zip Code
_________________________________  Telephone number:  (______)_________________________ 
                                 County (for Alabama residents)                                                       Area Code and Number                 
Date of Birth:  month/day/year_____________________     Gender:  ٱ Male   ٱ Female
 
Social Security Number: __ __ __ - __ __ - __ __ __ __ Email Address: _________________________
 
Are you a legal resident of the State of Alabama?  ٱ Yes   ٱ No

Have you resided, or will you have resided, in Alabama for the twelve months preceding the date of planned
enrollment?  ٱ Yes   ٱ No  (Documentation may be required)

Have your parent(s) resided, or will they have resided, in Alabama for the twelve months preceding the date of planned enrollment?   ٱ Yes   ٱ No   (Documentation may be required)

2. -----------------------------------------------------------------------------------------------------------

Intended Major: __________________ Intended Minor: ___________________Undeclared: __________
                          (Follow this link for a list of academic programs)
3. -----------------------------------------------------------------------------------------------------------

Other names under which transcripts may be listed:____________________________________________
Previously applied to or attended Montevallo?  ٱ Yes  ٱ No    If "Yes" indicate year(s): ______________

I certify that I comply with the provisions of the United States Military Selective Service Act (50 U.S.C.
App. 543) by having registered with the Selective Service Board or that I am not yet 18 years of age and
I will register when required or that I am not required by law to register.

The information herein is complete and accurate.  I understand that incomplete and inaccurate
application information may result in my being ineligible for admission and enrollment.

Signature: ________________________________________________________Date: _____________
 

The University of Montevallo is an equal opportunity educational institution and does not discriminate on the basis of age, color, creed, handicap, national origin,
 race, religion or sex.

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