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Student Information


If male, aged 18 to 26, please provide your Selective Service Number. To look up your number go to

Current Address


Returning Information

Have you resided in Ohio for the immediate past 12 months?
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Demographic Information

Your response in this section is voluntary. Information will not be used in a discriminatory manner and will remain confidential as to the individual, but may be used in general submission data.

Are you Hispanic?
Please select one or more of the following categories to describe yourself:

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Previous Education

List all colleges attended with most recent first:

College Names
College City/State
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Emergency Contact Information

In the event of emergency, notify:

Release of Information

Zane State College has permission to release my name, address, telephone listing, college major, dates of attendance, degrees and awards received (including dean’s list) and most recent previous education agency or institution attended to news media or other appropriate agencies.

I hereby certify that all statements on this form are correct and understand that I may be required to provide documentation at some future date to substantiate my claim and that any misrepresentation of this data may result in the cancellation of my enrollment or registration status and is considered a breach of academic honesty.