Internet Signature Page

Internet Application

Admissions Application Certification Form

Notice: To complete the application process, you must complete this form and mail it along with a $25.00 application fee to the address below.

SS# _________________________      Name ____________________________

Address ______________________     Telephone # _______________________

              ______________________

I have prepared my application using Delta State University’s Internet application.

I certify the information submitted on this form is correct and complete. I understand that failure to give complete and/or accurate information on this application could result in revocation of admission to Delta State University and cancellation of any subsequent enrollment. Furthermore, I agree to abide by the regulations of the University and to accept responsibility for payment of all charges incurred while I am a student.

Signature: __________________________      Date: ______________________

Mail this completed form to:

Office of Admissions

Delta State University

Kent Wyatt Hall 117

Cleveland, MS 38733