This is a printable form. Use the Print button to print and complete it by hand. Lines are visual guides for handwriting.
Student Application
Complete this form and include it with your application packet.
Program selection
Select one:
Certificate
Associate Degree
Select campus:
RELLIS Campus
Other:
Applicant information
Last name
First name
Mailing address
City / State / ZIP
Phone
Email
Blinn ID (if applicable)
Date of birth
College history
List all colleges attended (including Blinn). Attach additional pages if needed.
| College / University | Dates attended | Degree earned? | Notes |
|---|---|---|---|
| Yes No | |||
| Yes No | |||
| Yes No |
High school information
High school name
Year graduated / GED
Additional notes (optional)
Applicant certification
I certify that the information provided is true and complete to the best of my knowledge.
Applicant signature
Date