Fillable Return to Active Status Application for 3URIHVVLRQDO3KDUPDF\Students (University of the Pacific)

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Return to Active Status Application for 3URIHVVLRQDO3KDUPDF\Students (University of the Pacific)

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Return to Active Status Application for
3URIHVVLRQDO3KDUPDF\Students
This application is for: □Fall □Spring □SummHU _________BBBB
(year)
Note: This form has been designed to simplify the procedure for former Pacific students who seek to resume SURIHVVLRQDO study
at University of the Pacific. There is no fee involved in this application.Please submit this form to the Office of 3KDUPDF\Admission
at the address below.
Full Name: □Mr. □Ms. _________________________________________________________________
(last) (first) (middle) (preferred / nickname)
University ID: _________________________ Date of Birth: _________________
(98 Number) (mm/dd/yyyy)
Current Mailing Address: _______________________________________________________________
(number and street)
______________________________________ ________ _____________
(city) (state) (zip)
Permanent Mailing Address: _______________________________________________________________
(number and street)
______________________________________ ________ _____________
(city) (state) (zip)
Phone Number : _____________________ e-mail address: ___________________________________
What were the dates of your previous attendance at Pacific? What was your previous major?
___________________to_________________ __________________________________
(mm/dd/yyyy) to (mm/dd/yyyy)
List in chronological order all schools attended since you left Pacific. Please request each school listed to
send an official transcript to the University of the Pacific Office of Admission.
Name of Institution City / State of Institution Dates of Attendance Indicate any degree earned
Please check the school you want to return to:
□ Thomas J. Long School of Pharmacy and Health Sciences
Please indicate your prospective major:_______________________________________________________
Possible career objective: _________________________________________________________________
Why did you leave Pacific and what prompts you to return?______________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Since you left Pacific have you been dismissed, suspended, or placed on probation by any college or
university? □Yes □No If Yes, please explain: ___________________________________________
__________________________________________________________________________
If you have not been in school since last enrolled at Pacific, please summarize your activities :___________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
(If you have been a member of the Armed Forces, please submit a certified copy of DD Form 214. The Office of Admission will
evaluate your application and determine if you’re entitled to any credits.)
Other comments: _______________________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Are you a citizen of the U.S? □Yes □No. If No, please complete the following in the box below.
What is your country of citizenship? __________________________________________________
If you are currently in the U.S., what is you visa classification?
□ F □ J □ B2 □ Permanent Resident □ Other ____________________________
(please specify)
• If you are in the U.S., attach a copy of both sides of your I-94 Form (Arrival-Departure
Record) or a copy of your I-151 Form (Alien Registration Receipt card)
• If you are not a Permanent Resident, what is the date of expiration of your authorized stay in
the U.S.? ___________________________
(mm/dd/yyyy)
Please remember that if you are not a U.S. citizen or permanent resident, you may have to submit additional certification
regarding funding to enable us to issue you appropriate visa forms.
I hereby apply for “Return to Active Status” at the University of the Pacific and certify that the
information given on this form is accurate and complete, to the best of my knowledge, and I have attended
no institutions other than those listed above. I also agree to uphold the principles of Pacific student-
controlled Honor Code.
Date: ____________________ Signature of applicant _______________________________________
If there are any questions, please feel free to contact us: Office of Admission 3601 Pacific Ave., Stockton,
CA 95211, Phone: (209) 946-2211, Fax: (209) 946-2413 or email: admission@pacific.edu
.
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Return to Active Status Application for 3URIHVVLRQDO3KDUPDFStudents (University of the Pacific)

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Completed 31 August 2020

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