Basic Data Form

First Name *

Last Name *

Middle Name

Previous Names

UC ID#

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

County in the state in which you live (ex: Hamilton, Clermont) *

Years & Months of Consecutive residence in Ohio immediately preceding today: *

Phone Number

Phone Number with Area Code

E-mail *

Birth Month *

Birth Day *

Birth Year *

Sex *

Female Male

Males 18 years or older, are you registered with the Selective Service (www.sss.gov)

Yes No

Selective Service Number

U.S.Citizen *

Yes No

If not a citizen of the United States, list country of birth and country of citizenship *

If not a US Citizen, Type of Visa (ex. Perm. Res, A, H, L, TN, etc.) *

Ethnicity

Hispanic/Latino Not Hispanic/Latino

Race (check all that apply)

American Indian/Alaska Native Asian Black/African American Native Hawaiian/Pacific Islander White Other

High School Where You Attended: *

High School Graduation Year *

High School City and State *

Have you completed a Basic Data form in the last month?

Yes No

If you have selected yes. Please stop and login into Catalyst to review your active program or contact the Registrar's Office at Reginfo@uc.edu

Term you plan on enrolling *

Summer 2020 Fall 2020

UC Campus Where You Are PRIMARILY going to Enroll *

Uptown Main UC Blue Ash- undergraduate classes only UC Clermont-undergraduate classes only Senior Audit- for adults age 60 and older wishing to audit

Do You Plan To Enroll in *

Undergraduate level Classes Graduate level Classes

Have you ever applied to or attended UC? *

Yes No Not Sure

If Yes, Dates Attended UC

Degree(s) Earned at UC:

If you attended other institutions of Higher Education - List Institution's Name and Location

Dates Attended

Degree(s) Earned

Current Employer Name, City and State

Dates Employed

Academic Intentions - Please select all that apply *

To obtain knowledge for personal interest To be a visiting student from another campus To take only selected courses to gain skills before I start my career To take only selected courses to upgrade skills for a current job To take only selected courses to help me switch to a new career To take select courses in anticipation of applying for a degree or certificate program

Have you ever been found responsible for a disciplinary violationat any educational institution you have attended from the 9th grade (or theinternational equivalent) forward, whether related to academic misconduct orbehavioral misconduct that resulted in a disciplinary action, or are there anydisciplinary actions or investigations currently pending against you? Theseactions could include, but are not limited to: probation, suspension, removal,dismissal, or expulsion from the institution. *

Yes No

If yes please give the approximate date of each incident, explain the circumstances, and reflect on what you learned from the experience. *

Have you ever pled guilty or been convicted of a criminal offense, other than a traffic violation, or are there any criminal charges currently pending against you? Note that you are not required to answer "yes" to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded, orotherwise ordered by a court to be kept confidential. *

Yes No

If yes please give the approximate date of each incident, explain the circumstances, and reflect on what you learned from the experience *

I Understand

I Understand that my Basic Data Form will be processed for the term I indicated in the form.

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