Mind Making by G1A988C3

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									                                                                                                                              The University of New Mexico
                                                                                                                                 Extension Credit Program
                                                                                                                                       Extended University
                                              APPPLICATION FOR EXTENSION COURSES (505) 277-1154

1. Legal Name – please print below your full legal name as you would like it to appear on your educational records.

___________________________________________________________________________________________________________
Last                                       First                                                     Middle

2. Previous last name(s):_______________________________________________________________________________________

3. Social Security Number:
* The Federal Privacy Act of 1974 requires that you be notified that disclosure of your SSN is mandatory based on University regulation. Your SSN is used to ensure an
accurate academic record and to provide full access to all services such as financial aid. Your SSN will not be used as your primary University Identification number. If you are
unable to provide a SSN, the University will assign an alternative number to you. This will not impact the admission decision.

4. Your mailing address:________________________________________________________________________________________
                          Number and Street or PO Box

                                   ______________________________________________________________________________________
                                   City                                       State                               ZIP

Email Address:                     ______________________________________________________________________________________

5. Home Phone:                                                                    Cell Phone:

6. Gender:             Male                    Female                                      7. Birth Date:
                                                                                                                Month            Date             Year
8. Birth Place:_______________________________________

9. Are you a United States Citizen? Yes                               No          Alien Registration Number____________________________________

If foreign, indicate country_____________________________________ Visa Type_________________________________________

10. High school attended _______________________________________________________ Date of graduation_________________
                           Name                        City                  State

11. If not a high school graduate, have you earned a GED certificate? Yes                                No           Date earned__________________________

12. Application for:               Fall         Spring           Summer                       Year _______________________

13. Ethnic Information (The University is required by law to request this information.)
         African American, Black              American Indian (Principal tribal group: )_______________________________________
                                              Apache, Southern Ute, Navajo, Native Alaskan, Other
                                              Are you an enrolled member of a tribe?                             Yes     No

           Asian or Pacific Islander                       Hispanic                           White, Non-Hispanic                            Prefer not to specify

I desire to enroll in the following extension credit course:
     Title of Course               Course Number                               Hours Credit*                             Fees                         Instructor
Mind in the Making             CMTE 593                    3                                                $302.10                             Andrea Cameron


*PDCC Courses may qualify for graduate degree credit. To do so, the student must have the course approved by the appropriate degree-granting unit as
part of a program of studies. The student should check carefully with the degree-granting unit before assuming credit will be counted toward a degree.

14. Have you previously attended the University of New Mexico in any status?                                                                             Yes         No
                                                                       If yes, date:_______________________

15. Have you ever been denied admission to UNM for degree status?                                                                                        Yes         No

16. Have you ever been suspended from any college or university (including UNM) for any reason?                                                          Yes         No

           Institution and date of suspension___________________________________________                                          Academic               Disciplinary

17. Have you ever been convicted of, pled guilty to, or charged with a felony offense in any court?                 Yes      No
        If yes, you must attach an explanation. You are under a continuing obligation to immediately update your response to this
        question if your circumstances change after you submit this application.
18. List all colleges and universities ever attended in any status. Include enrollments at UNM and UNM Branches. Failure to provide
complete information may result in delay of admission, loss of transfer credit, and/or dismissal.
      Name of Institution                 City and State                             Date                        Degree Received
                                                                 From (month/year)        From (month/year)



You must answer every question, including state and date.

19. Did your parents or legal guardian claim you as a dependent on federal income tax returns in the              Yes      No
immediate past year? If you are under the age of 23 or answered “yes” to question 19, you must also
 answer questions 21-28 of “Parent/Guardian/Spouse” section in addition to the “Yourself” column. You
 may be asked to submit a copy of page one of your parent’s or guardian’s New Mexico income tax return for the immediate past year.

20. Are you a non-resident married to a New Mexico resident?                                                                                        Yes        No
If yes, answer questions 21-28 in “Yourself” and “Spouse” column. You may be asked to submit proof of marriage.

If you answered “no” to either question 19 or 20 above, answer questions 21-28 in the “Yourself” column only.
                                                                Yourself                             Parent/Guardian/Spouse
21. What state do you regard as your
permanent home?
22. Have you lived in New Mexico for the       Yes      No                                 Yes       No
past 12 months?
23. Dates and reasons you have been            Dates:                                      Dates:
absent from the state                          Reasons:                                    Reasons:
24. Are you a registered voter?                Yes      No                                 Yes       No
                                               State:                                      State:
25. Do you have a current driver’s license? Yes         No                                 Yes       No
                                               State:                                      State:
                                               Date Issued:                                Date Issued:
26 Do you own a vehicle?                       Yes      No                                 Yes       No
                                               State:                                      State:
                                               Registration Date:                          Registration Date:
27. Have you filed New Mexico tax              Yes      No                                 Yes       No
returns?                                       Calendar years you have filed:              Calendar years you have filed:

28. List employers and dates of                           Employer:                                                 Employer:
employment during the last two years:                     Dates:                                                    Dates:
                                                          Employer:                                                 Employer:
                                                          Dates:                                                    Dates:

29. Have you ever attended UNM while on a competitive or athletic scholarship,                                 Yes                                             No
tuition reciprocal agreement, or student exchange program?                     If yes, date:__________________

30. Have you ever paid in-state tuition at an Institution outside New Mexico?                                                                       Yes        No
                                                                                                      If yes, date:__________________

31. Do you intend to maintain permanent New Mexico residence?                                                                                       Yes        No

32. Are you a certified member of the Navajo tribe?                                                                                                 Yes        No
If yes, do you maintain permanent residence on the reservation?                                                                                     Yes        No
If yes, to both questions you are eligible to claim residence for tuition purposes.
Please ask for a Navajo certification form from this office.

33. Are you a member or a dependent of a member of the US Armed Forces who is stationed in New Mexico?                                              Yes        No
Note: Members of the US Armed Forces (or their spouses or dependents) may claim residence for tuition purposes during the period they are assigned active duty within the
state of New Mexico. Please contact the Office of Admissions for more information.

By signing below, I authorize UNM to bill my UNM account. Tuition, fees, and outstanding charges must be paid in the Bursar’s Office
by the posted financial disenrollment deadline each semester. I am familiar with the academic regulations of the University of New
Mexico and I am solely responsible for complying with all UNM regulations as stated in the UNM catalog.

I certify that all information given in this application is complete and accurate to the best of my knowledge. If I am accepted as a student
at the University of New Mexico, I agree to conform and abide by the letter and spirit of all rules, regulations, and procedures of the
University. Misrepresentations in any statement by the applicant or failure to abide by University academic regulations will be
considered adequate grounds for denying admission, for cancellation of registration, or for suspension from the University.

Signature_________________________________________________________________Date_______________________________

Social Security Number______________________________________________________Date of Birth_________________________
                        The University of New Mexico is an Affirmative Action /Equal Opportunity Institution.

								
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