Graduate Student Records Update Form by brokeNCYDE


									Return to:                                             UNIVERSITY OF WISCONSIN-STOUT                                                   OFFICE USE
The Graduate School
University of Wisconsin-Stout                  Graduate students who did not attend the previous semester
                                                          must complete and submit this form                                            Resident
PO Box 790
Menomonie, WI 54751-0790                                                                                                                Non-Resident
Phone: 715/232-2211
Fax: 715/232-2413
E-mail:          Graduate Student Records Update Form
Reentry Term                                                                                           Stout ID OR Social Security Number
Year                       Semester:            Fall           Spring         Summer

Last                            First                               Middle                   Maiden                          Other

       Date of Birth
                                                                 United States Citizen
                                                                  Yes         No     If no, Country of Citizenship
       U.S. Veteran           Yes         No                      Permanent Resident               Registration Number

                                                                  Non-immigrant Alien
 Permanent Home Address                                Mailing Address
                                                       if different from permanent address                            Telephone Number
                                                       Street                                                           include area code
  State                       Zip
                                                       State                      Zip                                   E-Mail Address
       From              To
                                                         From                To

 The following information is used to determine Wisconsin Residency for billing purposes. Wisconsin residency is defined by Wisconsin State
 Statues and is not the same as other residency.
List former addresses within the last two years                         From (MM/YY) To (MM/YY)               Are you a legal resident of the state
                                                                                                              of Wisconsin?
                                                                                                                     Yes          No
                                                                                                                     If yes, for what years?

                                                                                                              Have you filed Wisconsin State
Name and location (city, state) of high school from which you graduated                                       income tax returns?
                                                                                                                       Yes             No
Parents home address(es) within the past 12 months                      From (MM/YY) To (MM/YY)                      If yes, for what years?

                                                                                                              When/Where did you last vote or
If parents are deceased, give home address(es) for the 12 months preceding their death(s).                    register to vote?
                                                                                                              City             State    MM/YY

          I certify that the information presented on this form is true and that I understand submission of fraudulent record information to be
          cause for denial of admission.
                  Applicant's Signature                                                            Date
       The Student Business Office also requires that you have a current Fee Payment Agreement form on file with them before you can register.
                                You complete this form online through Access Stout. Refer to the following web page:

                                                              Print Form for your Records

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