1.
Email Address (REQUIRED)
*Required, Format: x@x.xx
2.
First Name (as it appears on your Social Security card)
*Required, Maximum characters allowed: 30
Maximum characters allowed: 30
4.
Last Name (as it appears on your Social Security card)
*Required, Maximum characters allowed: 60
Maximum characters allowed: 30
7.
What is your birth name?
Maximum characters allowed: 30
*Required, Format: mm/dd/yyyy
9.
What is your mobile/cell phone number?
Format: 123-456-7890
10.
What is your Home Phone Number ((if different than mobile/cell)?
Format: 123-456-7890
11.
By providing my phone number(s) I understand I will receive important College related text messages and TTS (text to speech) messages from Southern State.
*Required
13.
Social Security Number
*Required, Format: 123-45-6789
17.
Race (select one or more of the following races:)
18.
Are you a veteran/service member? If βyesβ a copy of your military/service ID must be submitted to the Records Office.
*Required
*Required, Maximum characters allowed: 60
20.
P.O. Box (if applicable)
Maximum characters allowed: 60
*Required, Maximum characters allowed: 25
*Required, Format: 12345 OR 12345-6789 OR 123456789 OR A1B 2C3
25.
Have you lived in Ohio for the past 12 months?
*Required
26.
If no, previous state of residence
30.
Enrollment Classification
*Required
31.
Anticipated Enrollment Term
*Required
32.
Anticipated Enrollment Year Begin Date
*Required
33.
Which campus would you like to attend?
*Required
35.
My Educational Goal is
*Required
36.
High School / GED (name of high school or enter "GED" if applicable)
*Required, Maximum characters allowed: 120
37.
High School City / State
*Required
38.
Date of Graduation / GED Received
*Required, Format: mm/dd/yyyy
39.
Last College/University Attended
Maximum characters allowed: 120
40.
Last Attended College/University City
Maximum characters allowed: 25
41.
Last Attended College/University State
42.
Father's Highest Level of Education
43.
Mother's Highest Level of Education