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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