Basic Data Form Back Up

First Name

Last Name

Middle Name

Previous Names

UC ID#

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County in the state in which you live (ex: Hamilton, Clermont)

Years & Months of Consecutive residence in Ohio immediately preceding today:

Phone Number

Area CodePhone Number

E-mail

Birth Month

Birth Day

Birth Year

Legal Sex

Males 18 years or older, are you registered with the Selective Service (www.sss.gov)

Selective Service Number

U.S.Citizen

If not a citizen of the United States, list country of birth and country of citizenship

If not a US Citizen, Type of Visa (ex. Perm. Res, A, H, L, TN, etc.)

Ethnicity

Race (check all that apply)

High School Where You Attended:

High School Graduation Year

High School City and State

Have you completed a Basic Data form in the last month?

If you have selected yes. Please stop and login into Catalyst to review your active program or contact the Registrar's Office at Reginfo@uc.edu

Term you plan on enrolling

UC Campus Where You Are PRIMARILY going to Enroll

Do You Plan To Enroll in

Have you ever applied to or attended UC?

If Yes, Dates Attended UC

Degree(s) Earned at UC:

If you attended other institutions of Higher Education - List Institution's Name and Location

Dates Attended

Degree(s) Earned

Current Employer Name, City and State

Dates Employed

Academic Intentions - Please select all that apply

Have you ever been found responsible for a disciplinary violationat any educational institution you have attended from the 9th grade (or theinternational equivalent) forward, whether related to academic misconduct orbehavioral misconduct that resulted in a disciplinary action, or are there anydisciplinary actions or investigations currently pending against you? Theseactions could include, but are not limited to: probation, suspension, removal,dismissal, or expulsion from the institution.

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 pled guilty or been convicted of a criminal offense, other than a traffic violation, or are there any criminal charges currently pending against you? 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, orotherwise ordered by a court to be kept confidential.

If yes please give the approximate date of each incident, explain the circumstances, and reflect on what you learned from the experience

I Understand

Please email us for Basic Data Form accessibility assistance