MICHIGAN UNDERGRADUATE GUEST APPLICATION
(Please follow the instructions on the reverse side of this page)
PART I (To be completed by applicant)
1. Name:
Last (Maiden) First Middle Additional Name(s)
2. *Social Security #: ______________ _______ UIC #:________________ _______ ________ ___
3. *Sex:
□
M
□
F 4. *Birth Date: 5. Citizenship (Country): (Visa Type)
6a. *Ethnicity: □ Hispanic/Latino □ Non-Hispanic/Non-Latino
6b. *Race: (May select one or more)
□ American Indian or Alaskan Native □ Asian □Black or African American □ Native Hawaiian or Other Pacific Islander □ White
*Information is optional and is requested to fulfill obligations to the Federal Government. This information will not be used in a discriminatory
manner and will be held confidential. Failure to respond will not subject applicant to adverse action.
7. Current Address: Phone: (
)_
No., Street, City, Zip
8. Home Address: Phone: ( )_
No., Street, City, Zip
9. Email Address: 10. Are you a veteran?
□ Yes □ No
11. S
tate of Legal Residence _______County of Legal Residence: Legal residence since:
12. Guest Application to:
College or University, City, State
13. Guest Term Dates: to
Month, Year Month, Year
14. Have you previously applied for admission to this institution? □ Yes □ No If Yes, when
15. Have you previously attended classes at this institution?
□
Yes
□
No If Yes, please indicate dates:
16. Courses that you plan to take:
Course Number(s), Title(s)
Please note that the courses listed will not guarantee enrollment at the guest institution, or transferability to the home institution.
I certify that the above statements are true. I agree to abide by the regulations of the institutions named above while I am
enrolled. I authorize the release of any records from my home institution which the guest institution may require.
Student’s Signature:
Date:
PART II (To be completed by an official at the institution in which the student is currently enrolled)
1. Institution currently or last enrolled:
College or University, City, State (Home Institution)
2. Enrolled Status: Currently Enrolled?
□ Yes □ No
If no, Last Date of Attendance:
3. Academic Standing: “C” Average or Better? □ Yes □ No Eligible to Return? □ Yes □ No
4. Number of credits completed at home institution?
I certify that the statements in Part II are true.
Signature of School Official Title Date Phone No. Seal
NO
T OFFICIAL WITHOUT COLLEGE/UNIVERSITY SEAL
(Revised 08/11)
