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What Class(es) Are You Interested In?

Name

First

Middle

Last

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Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Date of Birth

Phone

Sex

Male

Female

Other

Employer

High School

Did you graduate high school?

Yes

List school & grad year:

Do you have a GED?

Yes

Race/ Ethnic Group

Citizenship

Please Answer All Questions

Does anyone claim you as a dependant on their Federal Income Taxes (other than a spouse)?

Yes

Are you a resident of Pennsylvania?

Yes

For how long have you been a resident as of the beginning of the term you are applying for?

Will you have attended a college or University within the last twelve months?

Yes

Name of School:

Start Date

Start Date: Month

Start Date: Year

End Date

End Date: Month

End Date: Year

Did you attend In-Pennsylvania?

Yes

Did you attend Out-of-Pennsylvania?

Yes

Have you been employed continuously for the last twelve months or longer?

Yes

Have you been employed In-Pennsylvania?

Yes

Have you been employed Out-of-Pennsylvania?

Yes

Optional Questions

Are you an educator seeking ACT 48 credits?

Yes

Does your employer provide you with a tuition reimbursement plan?

Yes

The information given is true and correct. I understand that falsification of any data may result in dismissal. I authorize any employer, education institution or agency to release such data as is required by the University to verify the above information.

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