UNDERGRADUATE NON-DEGREE ENROLLMENT FORM

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Reynard Mitchell Bradford
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1 UNDERGRADUATE NON-DEGREE ENROLLMENT FORM UNDERGRADUATE STUDENTS ONLY: You WILL NOT be eligible for o-degree erollmet if ay of the followig statemets apply to you. If you have: Previously atteded T.U. as a degree seekig studet ad did ot graduate. Istead, cotact the Registrar s Office at for a re-erollmet form. Do NOT complete this form. Applied to Towso as a degree seekig studet but were deied admissio at ay time durig the past two years. Graduated from high school withi the past two years. Exceptios to this policy will be made if you are attedig as a degree studet at aother istitutio. Erollmet ito the uiversity does NOT guaratee erollmet i a particular class. Please verify class availability with the Registrar s Office at A NON-REFUNDABLE $45.00 FEE MUST ACCOMPANY THIS FORM (check, Visa, Discover or MasterCard oly). Please make checks payable to Towso Uiversity. q Check q Visa q Discover q MasterCard Credit Card # Expiratio Date: Sectio 1. Erollmet Term Idicate the term you pla to eter Towso Uiversity. q Sprig q Summer q Fall q Miimester Have you submitted either a applicatio or erollmet form for a previous term? For which term did you previously apply? q Sprig q Summer q Fall q Miimester Year: Did you atted classes? Sectio 2a. Persoal Data Social Security umber (optioal): - - TU ID (if kow) Complete legal ame: Last/Family Name First/Give Name Middle Name Previous surame(s): (Optioal used for matchig documets set uder previous ame(s); ot used to determie eligibility for admissio.) Date of birth: / / Geder: q Male q Female Your address: Number ad Street/Box No. Apt. No. Couty ( ) ( ) City State ZIP/Postal Code Coutry Home Phoe Cell Phoe Name of q Paret(s) q Guardia q Spouse: Their/his/her address: Number ad Street/Box No. Apt. No. Couty ( ) ( ) City State ZIP/Postal Code Coutry Home Phoe Cell Phoe Their/his/her Sectio 2b. Ethic Origi Colleges ad uiversities are asked by may groups ad agecies, icludig federal, state ad local govermets, to describe the racial/ethic backgrouds of their studets. I order to help us respod to these surveys ad to report this iformatio, please aswer both questios. 1. Are you of Hispaic or Latio origi? (A perso of Cuba, Mexica, Puerto Rica, South or Cetral America, or other Spaish culture or origi, regardless of race) 2. What is your race? Select oe or more of the followig categories, as appropriate: (The defiitios above ad below are provided by the Natioal Ceter for Educatio Statistics.) q White (A perso havig origis i ay of the origial peoples of Europe, the Middle East, or North Africa) q Black or Africa America (A perso havig origis i ay of the black racial groups of Africa) q Asia (A perso havig origis i ay of the origial peoples of the Far East, Southeast Asia, or the Idia subcotiet icludig, for example, Cambodia, Chia, Idia, Japa, Korea, Malaysia, Pakista, the Philippie Islads, Thailad, ad Vietam) q America Idia or Alaska Native (A perso havig origis i ay of the origial peoples of North ad South America, icludig Cetral America, ad who maitais cultural idetificatio through tribal affiliatio or commuity attachmet) q Native Hawaiia or Other Pacific Islader (A perso havig origis i ay of the origial peoples of Hawaii, Guam, Samoa, or other Pacific Islads) DO NOT WRITE IN THIS SPACE: FOR OFFICE USE ONLY q WA Check No. [ 1 ]

2 Sectio 3. Citizeship Are you a U.S. citize? If you are ot a U.S. citize, please complete this sectio. If you hold a visa, permaet residet card, are a refugee, or have bee grated asylum, provide photocopies of the documets you have bee issued. Photocopy the frot ad back of the permaet residet card. Coutry of citizeship: Coutry of birth: No-Immigrat status i the U.S.: Date of status: / / Refugee status: Date received: / / Permaet residecy umber: Date of issue: / / Is Eglish your ative laguage? If o, what is your ative laguage? FOR ISSO USE ONLY: Immigratio classificatio Valid util Immigratio status: q permits q does ot permit cosideratio for i-state tuitio eligibility. (If status permits cosideratio, studet applies by completig the reverse side of this form.) Studet cleared to eroll. ISSO, please sig ad date: Sectio 4. Military Service (aswer all questios that apply to you) Brach of Service: Date etered: / / Date released: / / Were you active duty for at least a year? Are you a disabled vetera? Are you a depedet of a vetera, ad eligible to receive VA beefits? Do you eed Early Out papers to be prepared i order to atted Towso Uiversity? Sectio 5. High School History High school curretly attedig (or from which you graduated) City State ETS code umber Date of high school graduatio/departure: / GED test date (if ot a high school graduate): / Moth Year Moth Year Sectio 6. College or Uiversity Attedace IMPORTANT: Please begi with the most recetly atteded or curret istitutio. List every school you have atteded, whether you eared credit or ot. Iclude cocurret erollmet experiece if courses were take while i high school. NAME OF INSTITUTION LOCATION DATES OF ATTENDANCE CREDITS ETS CODE (Please do ot abbreviate) (City, State) (Moth/Year) DISCIPLINARY RECORD: Aswer each questio below. A affirmative respose to either questio will ot result i a automatic deial of erollmet. All relevat circumstaces will be cosidered. The uiversity reserves the right to request further iformatio from the applicat to verify the iformatio disclosed. Providig false iformatio to these questios will be grouds for rejectig your applicatio, or, if you are erolled, expulsio. A) Are you i good stadig at all previous istitutios that you atteded ad eligible to retur? If o please explai the reaso you are ot i good stadig ad iclude i your explaatio the ame of the istitutio to which you are ieligible to retur. B) Has discipliary actio bee iitiated or take agaist you at ay of the istitutios you atteded? If yes please explai ad iclude i your explaatio the ame of the istitutio takig discipliary actio, the date of the ifractio, ad the discipliary actio take. [ 2 ]

3 Sectio 7. Residecy Iformatio for Tuitio Determiatio Do you wish to be cosidered for i-state tuitio status? (If yes, you must complete this sectio of the applicatio.) IF ANY OF THE CATEGORIES BELOW APPLY, PLEASE CHECK THE APPROPRIATE BOX, PROVIDE REQUESTED INFORMATION AND/OR DOCUMENTATION. q I am a part-time (50%) or full-time regular employee of the Uiversity System of Marylad or I am the spouse of, or am fiacially depedet upo a paret or legal guardia who is, a regular employee of the Uiversity System of Marylad. Please idicate relatioship: Please attach a letter of verificatio from the Huma Resources Office of the campus at which you or your spouse or paret or legal guardia is employed. q I am a full-time active member of the U.S. Armed Forces whose home of residecy is Marylad or oe who resides or is statioed i Marylad, or the spouse or a fiacially depedet child of such a perso. Please attach a copy of your deed or lease (if applicable), or verificatio from the service that you have declared Marylad as your home of residecy (if applicable); ad the most recet assigmet orders. Also, please idicate date of expected separatio from the military: q I am a vetera of the U.S. Armed Forces residig i Marylad. Please submit a copy of your DD214. If you have a discharge category other tha hoorable, please also submit a copy of your Certificate of Eligibilty. q I am the spouse or child of a vetera of the U.S. Armed Forces usig educatioal beefits uder the Post-9/11 GI Bill (38 U.S.C. 3311(b)(9) or 3319) ad livig i Marylad. Please submit a copy of the vetera s DD214 ad a copy of your Certificate of Eligibility. q I am eligible for i-state status cosideratio uder the Marylad Natioal Guard Noresidet Tuitio Exemptio. I am eligible because I (1) joied or subsequetly served to provide a critical military occupatioal skill or (2) am a member of the Air Force critical specialty code. I uderstad that I must provide documetatio of my eligibility from my Compay Commader for cosideratio. APPLICANTS SEEKING IN-STATE STATUS AS A MARYLAND RESIDENT MUST COMPLETE THE FOLLOWING QUESTIONS. Failure to complete all of the required items may result i a o-marylad residet classificatio ad out-of-state charges beig applied. Residecy classificatio iformatio is evaluated i accordace with the Uiversity System of Marylad policy o residecy. The applicat may be cotacted for clarificatio of a item, or for additioal iformatio as ecessary. PLEASE CHECK ONE: q I am fiacially idepedet. I have eared taxable icome ad I have ot bee claimed as a depedet o aother perso s most recet icome tax returs. q I am fiacially depedet o aother perso who has claimed me as a depedet o his/her most recet icome tax returs or I am a ward of the state of Marylad. If a ward of the state, please submit documetatio ad go to item 10. Name of perso upo whom depedet ad relatioship to applicat: a. How log have you bee depedet upo this perso? b. Is the perso a residet of Marylad? c. Address of this perso: _ d. Has this perso filed a Marylad state icome tax retur for the most recet year o all eared taxable icome? i. If a Marylad tax retur has ot bee filed withi the last 12 moths, state reaso(s): e. Sigature of this perso: _ cotiued o ext page [ 3 ]

4 Sectio 7. Residecy Iformatio (cotiued) The Studet Applicat is resposible for completig items Permaet address: Legth of time at permaet address years moths If less tha 12 moths, provide previous address: Legth of time at previous address years moths 2. Did you move to Marylad primarily to atted a educatioal istitutio? 3. Are all, or substatially all, of your possessios i Marylad? 4. Do you possess a valid driver s licese? a. If yes, iitial date of issue b. I what state? c. Most recet date of issue d. I what state? 5. Do you ow ay motor vehicles? a. If yes, iitial date of registratio b. I what state? c. Most recet date of registratio d. I what state? 6. Are you registered to vote? a. If yes, i what state? b. Date of registratio: c. Were you previously registered to vote i aother state? 7. Have you filed a Marylad state icome tax retur for the most recet year? If a Marylad tax retur has ot bee filed withi the last 12 moths, state reaso(s): 8. Is Marylad state icome tax curretly beig withheld from your pay? If o, provide explaatio. 9. Do you receive ay public assistace from a state or local agecy other tha oe i Marylad? a. If yes, idicate type ad issuig state: I certify that the iformatio provided is complete ad correct. I uderstad that the uiversity reserves the right to request additioal iformatio if ecessary. I the evet the uiversity discovers that false or misleadig iformatio has bee provided, the studet applicat may be billed by the uiversity retroactively to recover the differece betwee i-state ad out-of-state tuitio for the curret ad subsequet terms. 10. Sigature of Applicat Date [ 4 ]

5 Sectio 8. Cadidate s Agreemet (please read carefully ad sig) I certify that the iformatio provided o this form is correct. I uderstad that the uiversity reserves the right to request additioal iformatio if ecessary. Immuizatio Requiremets: Studets plaig to take a course at TU at ay time must meet the uiversity s immuizatio requiremets. I ackowledge that I must provide proof of immuizatio (Immuizatio Record), to the Dowell Health Ceter. I uderstad that failure to provide proof of immuizatio may delay registratio from further semesters. For more iformatio about Immuizatio Records please cotact: the Dowell Health Ceter ( ) or Office of Admissios ( ). The Health Form ad Immuizatio Record are available olie at the Dowell Health Ceter Web site ( I the evet the uiversity discovers that false or misleadig iformatio has bee provided, the Studet Petitioer may be billed by the uiversity retroactively to recover the differece betwee i-state ad out-of-state tuitio for the curret ad subsequet semesters. Failure to give complete ad accurate iformatio may also result i the cacellatio of registratio privileges. I agree to abide by the rules, policies ad regulatios of Towso Uiversity, icludig those cocerig the ulawful use of drugs or alcohol. Policy ca be foud i the Udergraduate Catalog, Appedix F. I completig this form, I accept ad agree to abide by the policies ad regulatios of Towso Uiversity cocerig drug ad alcohol abuse ad uderstad that the ulawful use of drugs or alcohol will subject me to the pealties cotaied i those policies ad regulatios. Sigature Date Mail to: Towso Uiversity Fax: Phoe: Office of Admissios 8000 York Road Towso, MD [ 5 ]

Authorization for Verification of Academic Records/Transcripts

Authorization for Verification of Academic Records/Transcripts Credetial Verificatio Service for New York State Authorizatio for Verificatio of Academic Records/Trascripts CGFNS Iteratioal P.O. Box 8628, Philadelphia, Pesylvaia 19104-8628 USA Phoe: +1 (215) 222 8454