Basic Data Form

First Name *

Last Name *

Middle Name

Previous Names

UC ID#

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

- Area Code Phone Number

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

Name of High School Where You Attended: *

High School Graduation Year *

High School City and State *

UC Campus Where You Are Enrolling *

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

Do You Plan To Enroll in *

Undergraduate level Classes Graduate level Classes

When Do You Plan to Enroll *

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

Since 9th grade, have you been disciplined at a school you have attended for academic or behavioral misconduct (Disciplinary actions could include, but are not limited to: probation, suspension, removal, dismissal, or expulsion.) *

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 been found guilty or convicted of a misdemeanor, felony, or other crime? (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, or otherwise ordered by a court to be kept confidential.) *

Yes No

If yes please provide an explanation of the conviction *

I Understand