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Distance Education ID/Library Card Application

Please take a moment to complete the following form. Carefully review each question.

If you need additional information, contact:

Red text Indicates required fields.

Student ID Number:
First Name:
Middle Name:
Last Name:
Mailing Address:
City:
State:		Zip:
Home Phone:
E-mail Address:

Identify your program of study:

Location of study:

Cohort number (if applicable):


Programs delivered through the School of Extended and Distance Education
1) Select program for which you are applying


2) Select program options
2a) If you are applying for Degree Completion Programs, choose one of the following:

If "Other", enter the name of the program

Cohort start date and location


2b) If you are applying for the Spectrum Program, choose one of the following:

If "Other", enter the name of the program

Cohort start date and location


2c) If you are applying for Individualized Study, choose one of the following:

If you answered "Degree Program" above, choose Degree Program (leave blank if you chose Nondegree coursework)
Bachelor Associate Certificate
Enter the name of the program (leave blank if you chose Nondegree coursework)

Check here if you would like to have a student id in addition to a barcode
Checking this option requires you to email studentids@mountainstate.edu a jpeg image of yourself so that it can be placed on the Student ID. If you have questions please contact James McGee at 1.800.766.6067 ext 1351

Mountain State University • PO Box 9003 Beckley, WV 25802

THIS SCHOOL IS AUTHORIZED UNDER FEDERAL LAW TO ENROLL NONIMMIGRANT ALIEN STUDENTS.