Basic Data Form - Online Bridge English Program

Basic Data Form - Online Bridge English Program

PROGRAM: 98UOP International Pathways-OPEN NMAT98-ELS "Bridge Program" G Program:98GOP International Pathways – G OPEN NMAT98-G Bridge Program
First Name/Given Name*
Last Name/Family Name*
Middle Name
Previous Names
UC ID#
Please add UCID if known
Street Address*
Street Address Line 2
City*
State / Province*
Postal / Zip Code*
Country*
Phone Number

Area CodePhone Number
E-mail*
Birth Month*
Birth Day*
Birth Year*
Sex*

FemaleMale
List country of birth and country of citizenship*
Type of Visa (ex. Perm. Res, A, H, L, TN, etc.)*
Ethnicity

Hispanic/LatinoNot Hispanic/Latino
Race (check all that apply)

American Indian/Alaska NativeAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteOther
Graduate or Undergraduate Student?

GraduateUndergraduate
Name of High School Where You Attended:*
High School Graduation Year*
High School City and State*
Have you been accepted to a University of Cincinnati Program this year?*

YesNo
Term you plan on enrolling*

Summer 2021Fall 2021
Have you ever applied to or attended UC?*

YesNoNot Sure
If Yes, Dates Attended UC
Degree(s) Earned at UC:
Academic Intentions - Please select all that apply*

To obtain knowledge for personal interestTo be a visiting student from another campusTo take only selected courses to gain skills before I start my careerTo take only selected courses to upgrade skills for a current jobTo take only selected courses to help me switch to a new careerTo take select courses in anticipation of applying for a degree or certificate program
Since 9th grade, have you been disciplined at a school you have attended for academic or behavioral misconduct (Disciplinary actions could include, but are not limited to: probation, suspension, removal, dismissal, or expulsion.)*

YesNo
If yes please give the approximate date of each incident, explain the circumstances, and reflect on what you learned from the experience.*
Have you ever been found guilty or convicted of a misdemeanor, felony, or other crime? (Note that you are not required to answer "Yes" to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded, or otherwise ordered by a court to be kept confidential.)*

YesNo
If yes please provide an explanation of the conviction*
Signature*

Clear
Should be Empty: