Consortium Application for:
Fisk Dual Degree: Fisk Bridge: Meharry:
Last Name First Name Middle Name
Student’s ID number Date of Birth Place of Birth
If not a U.S. citizen, list VISA type Sex (M or F)
Check term for which you are applying (Year 20 ):
Fall Spring Maymester
First Summer Second Summer Other
Have you ever applied to Vanderbilt University before? (check one) YES NO If yes, when?
Have you ever attended to Vanderbilt University before? (check one) YES NO If yes, when?
**Have you ever been suspended or expelled from a school? (check one) YES NO
**Have you ever been adjudicated guilty or convicted of a misdemeanor, felony, or other crime? (check one) YES NO
[Note that you are not required to answer “yes” to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed,
annulled, pardoned, destroyed, erased, impounded, or otherwise ordered by a court to be kept confidential.]
**If you answered “yes” to either or both questions, please attach a separate sheet of paper that gives the approximate date of
each incident, explains the circumstances, and reflects on what you learned from the experience.
Are you Hispanic / Latino?
What is your race?
American Indian / Alaska Native
Black / African American
Native Hawaiian / Oth Pacific Island
Two or more races