Evening ESL Term : Fall 1 Fall 2 Spring 1 Spring 2 Summer ........ Year : ______________
PERSONAL INFORMATION:
Full legal name: Last First Middle Former or Maiden
Sex: Male Female ............................Birthdate: (month)________(Day)_________(Year)________
CU Student #: _____________________ ........ (If applicable) ........ SSN or TIN #: _________________________
Local Address: HOME WORK = Company Name: ____________________________________________
Address: (no. and street, Apt. #) _________________________________________________________________
(City) ___________________________, (State) _________________________, (Zip) _____________________
International Address:
No. and Street or P.O. Box _____________________________________________
City _____________________ Country ______________________________ Postal Code ___________________
Home Phone Day Phone Cell/Mobil Phone
E-mail :
Citizenship (IMPORTANT - Please bring the necessary documents on Registration and Placement night.):
U.S. Citizen (Bring your US passport to Registration and Placement night.)
Alien Registration # _____________________
Country of Citizenship: ___________________
Non-U.S. Citizen - temporary status: (Bring your passport and immigration documents to Registration and Placement night.)
Immigration Status (Visa Type): ___________________
Country of Citizenship : ______________
Ethnicity: (Please indicate):
African American or Black, not of Hispanic origin
American Indian or Alaskan Native - Tribe: _________________________________________
American Indian or Alaskan Native, Non-Tribe member
Asian or Pacific Islander
Hispanic, Chicano, Mexican American, Latino
Multiracial - define: ________________________________________
White, not of Hispanic origin
I do not wish to provide this information
Military (Selective Service) Registration Certification:
I certify that I am registered with the Selective Service.
I am not required to register with the Selective Service because:
I am a female.
I am in the U.S. Armed Forces: active duty
I have not yet reached my 18th birthday.
I am age 26, or older, by the first day of class
I am a non-immigrant alien lawfully admitted in the U.S.
1. Have you served, or are you now serving on active duty with the U.S. Armed Forces? No Yes,
if yes from: ________________ To: _________________
2. Are you a University of Colorado faculty/staff member? No Yes
3. Have you ever enrolled in courses at any campus of the University of Colorado? No Yes
If yes, most recent: Term: _____________ Year: _____________ Campus: _______________
4. Have you ever been placed on probation. suspended, expelled or been subject to official disciplinary action from any high school or postsecondary institution for any academic misconduct or behavioral misconduct? No Yes,
5.Do you have a pending criminal charge OR have you ever been convicted of a crime, made a plea of guilty, accepted a deferred judgment, been adjudicated, or been required to register as a sex offender? (Misdemeanor traffic offenses are exempt.) No Yes
Course Selection (Please select the course/courses you are interested in.):
Payment Information:
________Cash
________Money Order or a US Bank check payable to the "University of Colorado"
________Credit Card
I you are unable to attend Registration and Placement night, you may send or fax your completed application, payment, and supporting documentation to the address and fax number below. (Note: Do *not* send cash via mail.)
US Mail: International English Center, University of Colorado at Boulder, 1030 13th Street, Boulder, CO. 80302
FAX: (303) 492-5515____________________________________________________________________________________________
I hereby certify that, to the best of my knowledge, the information furnished on this application is true and complete. Please register me for the course(s) listed above. I agree to observe all campus policies and regulations including the University Honor Code. ...... 04/2007
Student's Signature: _______________________________________________________________
Date:
____________________