Fairleigh Dickinson University
This application is to be completed by students who previously attended Fairleigh Dickinson University and did not attend any other
college/university since leaving. No application fee is required.
Please type or print.
Last Name ________________________________________________ First _________________________________ Middle Initial _________
Maiden Name (if applicable) ____________________________________________________________________________________________
Permanent Address ____________________________________________________________________________________________________
City ______________________________________________________ State ____________________ Zip _______________________________
Home Phone (_________) ___________________________________ B usiness Phone (_________) __________________________________
Cell Phone (_________) ____________________________________ Email ______________________________________________________
Social Security No. ________________________________________ Date of Birth ________________________________________
Month Day
Gender: b Male b Female
A. Ethnicity (Optional; for statistical purposes only)
1. Are you Hispanic/Latino? b Yes b No
2. Regardless of your answer to the prior question, please indicate how you identify yourself. (Check one or more.)
b American Indian or Alaska Native b Asian b Black or African American b Native Hawaiian or Other Pacific Islander b White
B. Employment Information (Optional)
Employer _________________________________________________ Position ____________________________________________________
Business Address _______________________________________________________________________________________________________
City ______________________________________________________ State ________________________ Zip ___________________________
Will you receive tuition reimbursement from your employer?
b Yes b No
C. Citizenship Information
Are you a U.S. citizen? b Yes b No
Are you a permanent resident?
b Yes b No If yes, please provide your:
Alien Registration Number _________________________________ Country of Citizenship ________________________________________
D. Veteran Status
Are you a member of the U.S. armed forces? b Yes b No If yes, please complete the following:
Current military status:
b Active Duty b Reserves b Veteran (prior service) b Spouse or dependent b Separated
Branch of service:
b Air Force b Army b Coast Guard b Marine Corps b Navy b National Guard
E. Other Information
Have you ever been convicted of a felony? b Yes (Please explain using a separate sheet of paper.) b No
Have you ever been suspended, expelled or required to withdraw from any secondary or post-secondary institution?
b Yes (Please explain using a separate sheet of paper.) b No
I am reapplying as:
b Undergraduate/Full-Time b Undergraduate/Part-Time b Graduate/Full-Time b Graduate/Part-Time
I plan to enter FDU:
b Fall 20_____ b Spring 20_____ b Summer 20_____ b Winter Session 20_____ b Other _____________________________________
My preferred campus is:
b Metropolitan Campus (Teaneck, NJ) b Florham Campus (Madison, NJ) b Online b Off-Campus Site ______________________
My intended major is: ___________________________________________Concentration (if applicable): ___________________________
Please provide information about your previous enrollmen
t at FDU:
Major ___________________________________________________________ Concentration __________________________________________
Campus Attended ________________________________________
________ Dates Attended _________________________________________
Student ID (if known)_________________________________________
Please list any college or university you have attended since leaving FDU:
School Name City/State Credits Earned Dates Attended
____________________________________________________________________________________ from _____________ to _____________
____________________________________________________________________________________ from _____________ to _____________
I certify that the information on this application is complete and correct and I authorize the University to verify the information provided. I agree to
notify the Admissions Office of any changes in the information provided. The University reserves the right to deny admission and matriculation to
any applicant who, in the judgment of the University, is not qualified, may not benefit from the University’s educational programs or whose presence
or conduct may impact negatively on its program(s). Students applying for admission to the University agree to abide by all the rules and regulations
now or hereafter promulgated by the University. Any student failing to comply with such rules and regulations is subject to their application being
rejected, offer of acceptance being rescinded, enrollment being cancelled or other appropriate disciplinary actions. Submission of false information,
in this application or otherwise, is deemed a violation of University rules and regulations. The signing of this application constitutes an agreement on
the part of the student that they understand, agree to be bound by, the foregoing.
Signature of Applicant Date
Please mail or fax your completed application to the appropriate Admissions Office
at the campus where you plan to attend:
Undergraduate Adult &
Part-time Admissions
1000 River Road, H-DH3-10
Teaneck, NJ 07666
Phone: 201-692-2551
Fax: 201-692-7305
Graduate Admissions
1000 River Road, T-KB1-01
Teaneck, NJ 07666
Phone: 201-692-2554
Fax: 201-692-2560
Rev. 1.18
Undergraduate &
Graduate Admissions
285 Madison Ave., M-RI0-01
Madison, NJ 07940
Phone: 973-443-8900
Fax: 973-443-8088
Fairleigh Dickinson University is committed to providing equal opportunity to all qualified persons and does not discriminate on the basis of race, religion, creed, national
origin, sex, disability, age, sexual preference, sexual orientation, marital status, military status or veterans status with regard to recruitment, admission or matriculation.
click to sign
click to edit