The Hiram College Transfer Status Waiver Form

H I R A M C O L L E G E
TRANSFER STATUS WAIVER FORM

Vice President for Admission
Hiram College
P.O. BOX 96
Hiram, OH 44234
800/362-5280

APPLICANT: Please complete the top five lines of this form and give it to the Dean of Students (or equivalent) at the college/university you most recently attended. Your signature on the line below authorizes release of the information requested. ATTENTION Dean of Students: above, we have provided the address for the return of this information.

Name: ______________________________ _________________________ ____________________

Last First Middle

Permanent address: _________________________ ______________ ___________________ ________
Number and Street

_______________________ ____________________ ___________________ _________________

Town/City State Zip Country

Social Security Number: ________-________-________

I wish to apply for _____fall semester _____spring semester 199_____.

I HEREBY AUTHORIZE___________________________________________TO RELEASE THE INFORMATION
College/University

REQUESTED BELOW TO HIRAM COLLEGE

SIGNATURE ________________________________________________ DATE _____________________

DEAN OF STUDENTS: The above student has applied for admission to Hiram College. In order to act on his/her application, we must obtain information requested 2 below. It should be completed and returned as soon as possible, but no later than one month prior to the candidate's desired date of entry.

Name: _______________________________________ Position: ____________________________________
Please type or print

College/University: _______________________________________________________________________________

School Address: __________________________ _____________ ____________ _________ ____________

Telephone Number: __________/__________-______________

Dates of candidate's attendance: _______________________________________________________

Is this candidate in good academic standing and able to return to your college/university (check one)? _____yes _____no
(If no, please explain.) _____________________________________________________________________________
______________________________________________________________________________________________

Has this candidate been involved in any acts of dishonesty (check one)? _____yes _____no
(If no, please explain.) _____________________________________________________________________________
______________________________________________________________________________________________

Has this candidate been responsible for or involved in disorderly or disruptive behavior (check one)? _____yes _____no
(If no, please explain.) _____________________________________________________________________________
______________________________________________________________________________________________

The answers to the above questions are based on:

_____ records on file

_____ casual contact and observation

_____ (If no, please explain.) _______________________________________________________________________

______________________________________________________________________________________________

COMMENTS: We welcome all information that will help us evaluate the applicant as a candidate for admission to Hiram College.

SIGNATURE: _____________________________________ DATE: __________________

REMINDER: PLEASE RETURN AS SOON AS POSSIBLE, BUT NOT LATER THAN JULY 15 FOR GENERAL ADMISSION OR DECEMBER 1 FOR SPRING SEMESTER.

Name:	______________________________	_________________________	____________________
	Last	First	Middle

Permanent address:	_________________________	______________	___________________	________
		Number and Street

_______________________	____________________	___________________	_________________
Town/City	State	Zip	Country

Name:	_______________________________________	Position: ____________________________________
	Please type or print