Please fill out all information completely.  Your application cannot be processed without all the information listed.

Complete this form to initiate your admission into the University ofWisconsin-Platteville Business Administration at a Distance Program. If you plan to be a matriculated student, you must have OFFICIAL transcripts sent to the UW-Platteville Distance Learning Center from (1) your high school of graduation and all high school s attended (or GED certificate from the Department of Public Instruction or certified testing site) and (2) ALL educational institutions attended beyond high school. To be official, transcripts must come to us directly from the issuing institution; transcripts sent to us from a student will not be accepted or evaluated. 

You are responsible for requesting all of your transcripts.

1. Name: 
                            Last                        First                    Middle 

2. Previous Name(s) (if applicable): 

3. Social Security Number (mail in only):          -         -                    4. Gender: Male Female 

5. Date of Birth(mm/dd/yyyy: //  6. Place of Birth: 
                                                  Mo          Day          Year                                     City /State or Country 

7. Permanent Address (where you currently reside):
Street:     City/State: 
ZIP:   ZIP + 4:    Length of time here: 
County (if Wisconsin): Country (if not United States): 
Phone Number:  (Home)() (Work) ()
(daytime [8 a.m.­4 p.m. CST]) ()
E-mail:
8. Racial/Ethnic Heritage (OPTIONAL-Check one): African American/Black; Cambodian, Laotian, Vietnamese, Hmong admitted to United States after 12/31/75; Other Asian/Pacific Islander; Hispanic/Latino; White/Non-Hispanic;
American Indian or Alaskan Native, Tribal affiliation: 
9. Citizenship: Are you a U.S. citizen? Yes No.
If no, indicate country of citizenship: 
Are you a resident alien? Yes No. If yes, give alien registration number: 
If you are a permanent resident alien, submit a copy of your permanent resident alien card.
Are you a non-immigrant alien? Yes No. If yes, give Visa type (example: F1): 
Are you a refugee/granted political asylum? Yes No. If yes, attach a copy of your I-94.
10. Are you applying for federal & state financial aid? (degree-seeking students only) Yes No 
11. Are you a U.S. veteran? Yes No

12. List all professional training programs: 
13. I will be providing: DD214; Military education records: Form 2-1 or Form DD 295; 
DANTES transcript; USAFI transcript; CLEP (specific subject) score report 
14. List your employment history and/or activities (other than school) for the past two years: 

15. Are you submitting a detailed resume for evaluation? (degree-seeking students only) Yes No 

16. Name of High School of Graduation:   City: 
State or Country: Date of Graduation (mm/yyyy): /
17. In lieu of a high school diploma, have you completed one of the following? GED; High School Equivalency Diploma;
 Issued by State of:   Test date (mm/yyyy):/
18. List all institutions of higher education attended (even if you withdrew) including colleges, universities, vocational-technical schools, the institution that you are attending now, name of college for courses taken while in high school, extension programs, etc., and any degree(s) earned. Attach an additional page if needed. If you plan to be a matriculated student, please request that each school send your transcript to the Distance Learning Center. Failure to list all institutions may result in disciplinary action, rescission of admission, and/or invalidation of credits or degrees earned. 

19. Are you a Wisconsin resident and/or do you claim legal Wisconsin residence for tuition purposes? 
Yes No
 20. Have you, or your spouse, recently moved to Wisconsin to begin full-time employment, or do you expect to do so before beginning your enrollment? Yes No 
21. List your former addresses, if any, during the last two years: 

If you answered "Yes" to either #19 or #20 above, please answer #22 and #23. You may be asked to provide further information. If you answered "No" to #19 and #20, proceed to the next section. 

22. I last voted or registered to vote in: (state)/(mm/yyyy); 
I have lived continuously in Wisconsin since: /(mm/yyyy); 
I have held a driver's license only in Wisconsin since: /(mm/yyyy) 
I have registered my motor vehicle(s) only in Wisconsin since: /(mm/yyyy);
 I have filed a Wisconsin state income tax return as a resident every year since: 
23. Father's Name & Current (or Last) Address: 

Since /(mm/yyyy): Is he living? Yes No 
Mother's Name & Current (or Last) Address: 

Since /(mo/yr): Is she living? Yes No 

24. You must indicate what your student status will be. Contact the Distance Learning Center if you have any questions. 

STATUS 1: Matriculated Student 

• I intend to earn a degree from the University of Wisconsin-Platteville. 
• I understand that I must contact schools I have attended previously and request official transcripts be sent to the UW-Platteville Distance Learning Center for evaluation. 
• I understand that, as a matriculat ed student, I may be eligible to receive financial aid. 

STATUS 2: Special Student. List desired course(s): 

• I do not intend on seeking a degree from the University of Wisconsin-Platteville at a Distance at this time. 
• I understand that, as a special student, I am not eligible to receive financial aid. 
• I understand that I am not required to send my transcripts to UW-Platteville for evaluation.

I am enrolled at another institution and only need course work from UW-Platteville. Name of Institution: City/State: 

I want to take courses for personal enhancement not for the purpose of earning a degree from UW-Platteville.

I need to increase my academic standing before I enroll as a matriculated student. 

I am an on-campus UW-Platteville student. (Additional information may be required.) 

I intend to earn a degree from the University of Wisconsin-Platteville; however, I want to enroll in course work immediately while my transcripts are being evaluated.

Recommended by UW-Extension 

Recommended by another institution (list institution name): 

Saw brochure or other promotional materials distributed by UW-Platteville 

Saw television commercial 

Other: 

I certify that the information in this application is true and complete to the best of my knowledge, and I understand that inaccurate information may affect my enrollment, tuition, or financial aid status. I also understand that if I have applied for financial assistance, information concerning the amount of financial aid that I may be offered may be released to other agencies that may also be considering me for assistance. If I enroll at the University of Wisconsin-Platteville, I will abide by i ts rules and regulations.

Applicant's Signature:________________________________________   Date: ____________________

Note:
A nonrefundable $44 application fee (or transfer application fee) must be submitted at the time of application and is required for all: (1) students who are entering college for the first time, (2) students who are transferring from any non-UW System institution, and (3) students who are transferring from any UW baccalaureate (4-year) campus. The application fee is not required if you are only taking courses as a special student with us. Contact the Distance Learning Center if you have questions on whether or not you need to submit the fee.

Admission status:  Admitted,  Admission denied                   Financial aid status:_______________________
Admitted as:  New Freshman / Transfer / Reentry / Special Student / 2nd undergraduate degree 
Residency for tuition purposes: Resident / Nonresident 

Signature of University official: __________________________________  Date: ____________________