UC Clermont Micro-Credential Form
Which Micro-Credential are you pursuing?
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Computer Support Specialist
Electronic Health Records Specialist
Presentation Applications Specialist
Programming Primer: Fundamentals & Foundations
Spreadsheet Applications Specialist
Word Processing Applications Specialist
Writing in the Workplace
First Name
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Last Name
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Middle Name
Previous Names
Current or previous UC Student?
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Yes
No
UC ID# (if applicable)
Street Address
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Street Address Line 2
City
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State / Province
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Postal / Zip Code
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Phone Number
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Area Code
Phone Number
Date of Birth
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Month
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Day
Year
Date
Years & Months of Consecutive residence in Ohio immediately preceding today:
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Current UC or personal email
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U.S. Citizen?
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Yes
No
Ethnicity
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Hispanic/ Latino
Not Hispanic/Latino
Race (check all that apply)
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American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/ Pacific Islander
White
Other
High School Name, City and State
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High School Graduation date
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Month
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Day
Year
Date
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.)
Yes
No
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.)
Yes
No
I understand that I am requesting adding a micro-credential.
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I Understand
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