Fillable Application For Readmission

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Application For Readmission

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File type: PDF

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BROWSE UNIVERSITY OF PORTLAND FORMS

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Revised 10/2018
Application for Re-admission to Graduate School________________________
Completion of this form is required for students who have interrupted graduate studies for one
semester or longer. If another university has been attended in the interim, then a transcript of this
work may be required.
I am applying for re-admission: Semester Year______________
Name Student ID: Date______________
Permanent address and phone number:
______________________________________________________________________________
Mailing address and phone number (if different from above):
______________________________________________________________________________
Graduate Program ______________________________
Last semester of attendance at U of P Fall Spring Summer Year________
Other university attended in the interim? Yes No_____________________
If yes, name of university, dates attended, and number of credits taken:
______________________________________________________________________________
Please read and check the boxes before submitting your application.
Have you ever been dismissed, suspended, or placed on disciplinary probation by a high school
or college? Yes No
If yes, please explain your dismissal, suspension, or probation below.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
GRADUATE SCHOOL
5000 NORTH WILLAMETTE BOULEVARD
PORTLAND, OREGON 97203-5798
(503) 943-7107
TDD (503) 943-7484 / E-MAIL: <gradschl@up.edu>
Number/Street City State Zip Phone
Number/Street City State Zip Phone
University Name Date Credits Taken
Revised 10/2018
Have you ever been arrested or convicted of any violation? Yes No
If yes, please explain your arrest or conviction below.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
At the time of the end of your enrollment at your current college/university, or, if you are still a
student, were you or are you currently the subject of a disciplinary or student conduct charge or
proceeding? Yes No
If yes, please explain your disciplinary or student conduct charge or proceeding below.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I certify that to the best of my knowledge, all statements I have made herein are complete and
correct.
Signature Date__________________________
………………………………………………………………………………………………………
Recommended Not recommended
Signature Date__________________________
………………………………………………………………………………………………………
Approved Not approved
Signature Date__________________________
Graduate Program Director
Cc: Registrar; Graduate program Director; Graduate School
Graduate School, Dean
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Application For Readmission

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Completed 3 December 2019

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