UG Dual Enrollment Application

School Counselor Information

Counselor First Name

Counselor Last Name

Counselor Email

Student Information

First Name

Middle Name

Last Name

Preferred First Name

Birthdate

Contact Information

Email Address

Student Mobile

Do we have permission to text you?

Yes

Message and data rates may apply. You may opt out of text messaging at any time by replying STOP. View our privacy policy for more information on how we protect your data.

College or University Name

Start Date

End Date

Are you a first-generation student?
A first-generation student is a college student who is the first in their family (one or more parent does not have a four-year college degree) to go to and graduate from college.

Release of Academic Record or Student Account

Admissions Office (receipt of admission documents, application status)

Business Office (student balance)

Financial Aid Office (financial assistance, awards)

None

Signature

Admissions Agreement

By submitting this application. I understand that withholding information requested on this application, including attendance at any other institution, or giving false information may make me ineligible for admission to the college or subject to dismissal I have read this application and certify that the statements I have made on this application are correct and complete, including a report of all college work attempted or completed.

In addition to the forgoing, the Tennessee Eligibility Verification for Entitlements Act requires an applicant for in-state tuition or state financial aid to attest under penalty of perjury that he or she is either a United States citizen or alien lawfully present in the United States. By submitting this application, I am attesting that I am either a United States citizen or alien lawfully present in the United States or I am not requesting any state benefits including in-state tuition.

I understand that this attestation is required by Tennessee law if I have applied for a state public benefit. I understand that Tennessee la w requires me to provide documentation verifying the status indicated above prior to receipt of this state public benefit. I understand that knowingly and willfully making a false, fictitious, or fraudulent statement or representation shall subject me to liability under the Tennessee False Claims Act. Tennessee Code Annotated 4-18-101 et seq. I understand that if I am found to have made a false or misleading statement my state public benefit may be rescinded or I may be disciplined by the college.

Non-Discrimination Policy

Tennessee Tech is committed to ensuring that all individuals have equal access to its employment opportunities, educational programs, services, and activities. Tennessee Tech views, evaluates, and treats all students, employees, and applicants on the basis of their own personal abilities, qualifications, and other relevant characteristics.

Tennessee Tech does not condone and will not tolerate discrimination against any individual on the basis of race, religion, color, creed, sex, age, national origin, genetic information, disability, veteran status, and any other bases protected by federal and state civil rights law.

Tennessee Tech does not condone and will not tolerate retaliation against individuals who oppose illegal discrimination or participate in investigations of illegal discrimination pursuant to Tennessee Tech policies.

The following University offices have been designated to handle inquiries regarding non-discrimination and affirmative action at Tennessee Tech:

Office of Human Resources		Office of Compliance
Derryberry Hall 146		Title VI & Title IX Coordinator
Cookeville, TN 38505		Derryberry Hall 258
(931) 372-3034		Cookeville, TN 38505
Human Resources		(931) 372-6062
		Compliance

I give Tennessee Tech University personnel associated with and involved in Dual and Joint Enrollment my permission to release any information regarding my academic record or student account to the partnering educational institutions.

Please confirm you have read and agree to the statement above:

UG Dual Enrollment Application

IF you are a returning Dual Enrollment Student:

Admissions Agreement

Non-Discrimination Policy