FOR OFFICE USE ONLY:
Information Requested: ___________________
_______________________________________
_______________________________________
_______________________________________
CPA___________________________________
Degree_________________________________
Program________________________________
Specialization___________________________
Action/Date_____________________________
STUDENTS PREVIOUSLY ACCEPTED INTO A GRADUATE PROGRAM:
Original date of admission for graduate study:
Fall Spring Summer Year ____________
Did you begin taking classes :
Yes No If yes, date of last attendance: Fall Spring Summer Year ____________
STUDENTS WHO PREVIOUSLY APPLIED TO A GRADUATE PROGRAM BUT WERE WITHDRAWN OR NOT ACCEPTED:
Original date of application:
Fall Spring Summer Year ____________
RE-ACTIVATION REQUEST FOR:
Fall Spring Summer (available for selected programs) Year ___________
Full-time Part-time
PROGRAM SOUGHT:
New Program Prior program (no change in degree or major)
Degree_______________________________ Major______________________________________________________
Specialization (if applicable)_____________________________________
NAME:_______________________________________________________________________________________________
(Last) (First) (Middle)
FORMER NAME/OTHER NAMES:________________________________________________________________________
CCSU ID#:________________________________________SS#:(optional)_______________________________________
ADDRESS:____________________________________________________________________________________________
CITY:____________________________________________STATE:______________________ZIP:____________________
COUNTRY:_______________________________________EMAIL:______________________________________________
PHONE:(home)__________________________(cell)________________________(work)____________________________
Are you a citizen of the United States? Yes No If no, what is your country of Citizenship? __________________
Are you a legal resident of Connecticut? Yes No If yes, indicate years in Connecticut _______________________
If non-citizen check appropriate box: F1 or F2 student visa Eligible non-citizen Other visa
Permanent resident, list alien registration number _______________________________________________________
Are you a U.S. Veteran? Yes No
Have you taken courses at other institutions since your initial application to CCSU? Yes No
If yes, please list institutions. An official transcript must be sent to the Graduate Recruitment and Admissions Office from
each college attended. Consult the Graduate Catalog for Transfer Credit Polices.
Institution Name Location (City/State) Dates Attended Degree Awarded
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Student Signature ____________________________________________________________________ Date_____________
