INSTRUCTIONS:
The RE-ENROLLMENT FORM is for:
• Previously enrolled(continuing)
graduate students wishing to re-
enroll after 2 years (or more) of
being in an inactive or withdrawn
status.
• Active continuing graduate
students who have been withdrawn
for failure to pay the continuing
registration fee.
PLEASE COMPLETE THIS FORM
AND SUBMIT A $50
RE-ENROLLMENT FEE TO THE
ADDRESS LISTED BELOW. MAKE
CHECK PAYABLE TO CCSU.
RETURN TO:
Graduate Recruitment
and Admissions Office
Central CT State University
Henry Barnard Hall RM 102
1615 Stanley Street
New Britain, CT 06051-4010
If you completed your previous
Graduate program and wish to
begin new program, complete a
new Graduate Application for
Admission.
PROGRAM SOUGHT:
New Program Prior program (no change in degree or major)
Degree__________________________ Major___________________________________________________________
Specialization (if applicable)_________________________________________
RE-ENROLLMENT REQUEST FOR:
Fall Spring Summer (available for selected programs) Year __________
Full-time Part-time
ORIGINAL DATE OF ADMISSION FOR GRADUATE STUDY:
Fall Spring Summer Year __________
DATE OF LAST ATTENDANCE:
Fall Spring Summer Year __________
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
If permanent resident, list alien registration number: ______________________________________________________
Are you a U.S. Veteran? Yes No
Since your last date of attendance at CCSU, did you live and work in CT? Yes No
If not, please indicate the location(s) and years of duration (from-to) of your residency and employment.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
If you have taken courses elsewhere, please list institutions in the section below. An official transcript must be sent to the
Graduate Recruitment and Admissions Office from each college attended. Please notify your academic advisor if you
have taken courses that may be considered for transfer.
Institution Name Location (City/State) Dates Attended Degree Awarded
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Student Signature _______________________________________________________________ Date__________________
$50 Check Enclosed
FOR OFFICE USE ONLY:
Information Requested: ___________________
_______________________________________
_______________________________________
_______________________________________
CPA___________________________________
Degree_________________________________
Program________________________________
Specialization___________________________
Action/Date_____________________________
