MICHIGAN UNIFORM
UNDERGRADUATE GUEST APPLICATION
(Please read and follow the instructions
)
PART I (To be completed by applicant)
1. Name ___________________________________________________________
2. Social Security No. ________________________
Last
First
Middle
3. Sex* M/F 4. Birth Date * _______________
5. Citizenship ________________________ (Visa Type) _______________________
Country
6a. Racial/Ethnic Background* - please check only ONE category which best applies
to you:
Hispanic White(non-Hispanic)
Black (non Hispanic) Am.Indian, Eskimo or Aleut (AIEA)
Asian or Pacific Islander (API)
6b. Are you MULTIRACIAL? Yes
No
If you answer "yes," please
mark all of the races below that apply to you based on the list from item 6a:
Hispanic White(non-Hispanic)
Black (non Hispanic) Am.Indian, Eskimo or Aleut (AIEA)
Asian or Pacific Islander (API)
NOTE: For purposed of this question, you are multiracial
if you have parents from more than one of the broad race categories listed
in item 6a OR if at least one of your parents
is multiracial
7. Current Address ________________________________________________________
Phone (______)_________________________
No. Street
City
State Zip
8. Home Address ________________________________________________________
Phone (______)_________________________
No. Street
City
State Zip
9. High School ________________________________________________________
Graduation Date _________________________
Name
City
State Zip
10. State of Legal Residence _____________________________________
Country of Legal Residence ___________________________
The above
has been my legal resident since ______________________________________________________________________
11. Guest Application To _________________________________________________________________________________________
College or University
12. Guest Term Dates ______________________________________ to ___________________________________________________
Month/Year
Month/Year
15 Classes Planned to Take _______________________________________________________________________________________
Course Number
Title
I certify that the above statement are true. I agree to abide by the regulations
of the institution named above while I am enrolled. I authorize the release
of any records from my home institution which the guest institution may require.
_______________________________________________________________________________________________________________
Student's Signature
Date
*Optional and for Identification Purposed Only
Part II (To be completed by an official
at the institution in which the student is currently enrolled.)
1. Institution Currently or Last Enrolled _______________________________________________________________________________
College or University (Home Institution)
2. Enrollment Status: Currently Enrolled?
Yes No
Last Date of Attendance __________________________________
3. Standing: "C" Average
or Better? Yes
No
Eligible to Return? Yes
No
I certify that the statements in Part II are true.
______________________________________________________________________________________________________________
Signature
Title
Date
Phone No.
Seal
NOT OFFICIAL WITHOUT COLLEGE/UNIVERSITY SEAL
Revised 03/00)
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