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Statement of Intent to Return

Southeast Technical is asking you to provide private information in order to process your Statement of Intent to Return. This information will be used to update your academic record. You are not legally required to provide this information; however, the college may not be able to effectively process your request if you do not provide sufficient information. Access to this information will be limited to school officials, including faculty who have legitimate educational interests in the information. Under certain circumstances, federal and state laws authorize release of private information without your consent: to other schools in which you seek or intend to enroll, or are enrolled; to federal, state or local officials for purposes of program compliance, audit or evaluation; as appropriate in connection with your application for, or receipt of, financial aid; if the information is sought with a court order or subpoena; or as otherwise permitted by other state or federal law.
 
When do you plan to re-enroll at Southeast Technical?
Program/Major Choice?
When did you last attend Southeast Technical?
What major were you previously enrolled in?

Note: Effective July 1, 1990, students must provide proof of immunization against measles, mumps, rubella, diphtheria, and tetanus to the Southeast Technical Student Service Office.
Social Security#:
Last Name: FirstName: MI:

Has your name changed since you were last a student at Southeast Technical? Yes No

(If Yes, previous name)
Last Name: FirstName: MI:
Mailing Address:
City: State: Zip:
Permanent Address:
City: State: Zip:

Have you been a resident of Minnesota for at least one (1) year prior to completing this Intent to Return form? Yes No If no, what state?

Local Phone: Permanent Phone:
Cell Phone: Work Phone:

If you have attended any other college(s) since you last attended Southeast Technical, please list them below and give dates of attendance:

Student Signature:

Revised 10-11-04 ta | 05-25-05 cs