nnnnnnnnnnnnLast MaidenFirst Middle Additional Names UIC 3 Sex F 4 Birth Date 5 Citihip ryVisa Type Ethnicity HispanicLatino NonHispanicNonLatino ID: 891180
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1 n n n n n n n n n n n n MICHIGANUNDERGRD
n n n n n n n n n n n n MICHIGANUNDERGRDUATE GUEST APPLICATION(Please follw the insructons n thereverse side of this paPART I (To be completed by applicant)Name: Last (Maiden)First Middle Additional Name(s) UIC # _______________ ______ _____ 3. *Sex: F 4. Birth Date: 5. Citihip ry): (Visa Type) . *Ethnicity: Hispanic/Latino NonHispanic/NonLatino 6b. *Race: (May select one or more) American Indian or Alaskan Native □ Asian □Black or African American □ one: ( No., Street, tyHome Adres one: ( No., Street, tyEmail Address: 10. Are you a veteran? Yes 11. State of Legl Residence _______ County of Legal Rsidnce: l resie since: 12. Guest Applion to: ollege or ersity, ty, ate 13. Guest Term Dates: Month,YearMonh, Year 14. Have you prevously apied for adisson to this instiution? Yes No If Yes, when 15. Have you prevly attd classeat this institution? Yes No If Yes, please inicate dates: 16. Courses t yo CourseNumb), Title Please notethat the courses listed will not guarantee enrollmentat the guest institution, or transferability to the home institution. I certify that the abovtatements re trueI agree toabide bythe regulationsofthe instituions nove whI am enrolled.I authorize the release of any rords from myh
2 ome institu whichtheguest institumay req
ome institu whichtheguest institumay require.Student’s Signature: Date: PART II (Tobe completed by an official at the institution in which the student is currentlyenrolled)1. Institution currently laenrd: College or Uniersity, y, State (He Institution) 2. Enrolled Status: Curretly Enrolled? Yes If no, LastDate of Attendance: Academic Standing: “C” Averageor Better? Yes I certify that the statemnts in Part II are true. ignature of School OfficialTitle DaPhoneNo.SealNOTOFFICIALWITHOUTCOLEGE/UNIVERSITYSEAL(Reised 08/11 MICHIGANUNDERGRDUATE GUEST APPLICATION INSTRUCTION PAGE Thisformwillserveyourapplicatforadmission a gueststudent a Michigan college or niversity.Allprospectivestudents shouldcheckwiththeGuestInstitution determine if additional requirementsarerequredforadmissionenrollment.Thisformdoes not ensure transfrability coursestakentheGuestInstitution to theHomeInstitution.Specialattntionshouldpaid aprerequisite co-requisitecourse requirementsof the GuestInstitution wherethe course taken.FillPARTI ofthe application. Thtakeit totheRegistrar (orofficeryourschoolwho processesGuestApplications) wherePARTwillcompletedsigned. The completed GuestApplicationwill thsent frtheHomeInstitutionthe school which youare applying.GuestStudents......aresubject alltheadmission aregistrationregulatitheGuestInstitutionot hapermissionregister a degree candidatetheGuestInstitution.arerespnsibleerminethattheHome Institutionwillaccept credearned a guest studnt.mustunderstandthatfalsificationparttheGuestApplicationmayresultin cancellaion admission and/orregistration tGuestInstitution.mustarrangehave a transcriptguestcreditearned a gueststudent sent fromthe GestInstitution back the HomeInstitution.wishingapplyforfinancialaid shouldverifytheireligity withtheGuestInstitutiRevised08/1