Application for Admission Signature Page

    Note: Please make sure you have completed and submitted the on-line Jefferson College Admission Application prior to mailing this form to the Office of Admissions.

    1. Print a copy of this form.

    2. Complete the required information.

    3. Attach your $25.00 application fee.

    4. Mail the form to:

    Jefferson College
    Office of Admissions
    1000 Viking Drive
    Hillsboro, MO 63050

     

    Name:  __________________________________________________________
                       (First)                       (Middle)                      (Last)

    Telephone Number: (____)____________________________

    Date of Birth:     ____________________________

    Date of Application: __________________________________

    To be accepted for admission to Jefferson College, all new students must submit a one-time, non-refundable $25 application fee.

     You may:

    • Send a check or money order (payable to Jefferson College) for $25 with this form to:

      OR

    • Charge the application fee to your Visa or MasterCard. Complete the box below, print this page, and fax or send this form to the Jefferson College Office of Admissions.
      Fax #: (636) 789-5103

    MasterCard/Visa # _________________________

    Expiration Date ____________
                                    Month/Year

    Printed Cardholder Name ____________________________

    Cardholder Street Address ___________________________

    Zip Code ________________

    Signature________________________________

     
    I certify that all information submitted on my Application for Admission is complete and accurate to the best of my knowledge.  I understand that I must submit a one time $25 application fee and official high school transcripts, or diploma; official GED test scores or certificate; or official college transcripts in order to complete my application as a degree seeking student.  I understand that all application materials submitted become property of Jefferson College, and I may review them upon request with valid identification.

    Signature:___________________________________________  Date:_____________
    It is the policy of Jefferson College that no person shall, on the basis of age, ancestry, disability, gender, national origin, race, or religion, be subject to discrimination in employment or in admission to any educational program or activity of the college.

    NOTE:  If accommodations for a disability are needed, please contact Sundaye Harrison at (636) 481-3169; TDD users, call (636) 789-5772.

    Questions regarding this application or the content of this page should be directed toward the Office of Admissions, (636) 481-3217.