LaneCollege

Office of Admissions

545 Lane Avenue

Jackson, TN38301

731-426-7500

Application for LEAP

Lane Evening Accelerated Program

Name ______

LastFirstMiddle

Social Security Number ______Date of Birth ______/ ______/ ______

Permanent Address ______

City______State ______Zip Code ______

Home Phone ( ) ______Work Phone ( ) ______

Cell Phone ( ) ______Email ______

Wish to begin classes in ______Fall (August) ______Spring (January) ______Summer (May) 20______

Classification:______first-time freshman (no earned college credits)

______transfer (received college credits from another institution)

______readmit (previously attended Lane)

Intended Major: ______(see listing for five possible majors for LEAP)

Have you applied for financial aid*?______No______Yes, on ______

(Date)

Have you taken the ACT or SAT?______No______Yes, on ______

(Date)

Are you a U.S. citizen?______No______Yes

If no, what is your visa status? ______

Have you ever been convicted of a felony? ______No______Yes

If yes, give detail in a letter accompanying this application

List all schools and colleges previously attended. Please provide dates of attendance and anydegrees

earned.

NameDates AttendedDegree

High School ______

Two-YearCollege ______

Colleges/universities ______

*All applicants must complete the Free Application for Federal Student Aid (FAFSA) to become eligible to receive scholarships and/or other forms of financial aid.

Employer Information

Name/Company ______

Employer’s Address ______

City ______State ______Zip Code ______

Name of immediate supervisor ______

Telephone ______Years with current employer? ______

Does your employer provide tuition assistance? ______Yes ______No ______Don’t Know

List any family members who have attended or are currently attending Lane:

Name / Relationship

In case of emergency, contact:

Name ______Relationship ______

Address ______Phone ______

I certify that all information submitted by me on this application is true and complete. I understand that if

Any false information, omissions, or misrepresentations are discovered, my application may be rejected,

and my admission denied or revoked at any time.

I further understand and agree to the following stipulations:

  1. The Lane Evening Accelerated Program (LEAP) is separate and apart from the traditional LaneCollege academic program, and credits earned in LEAP are not transferable to any other institution.
  2. If I wish to transfer to the traditional LaneCollege academic program, I must make the request in writing. Upon approval, credits earned in LEAP are transferable to the traditional LaneCollege academic program
  3. If I transfer from LEAP to the traditional academic program, I may not transfer back to LEAP.
  4. LEAP is non-residential, and no temporary or permanent housing arrangements are available.

Applicant’s Signature ______Date ______