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UNIVERSITY OF WISCONSIN - MADISON - DOC

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					UNIVERSITY OF WISCONSIN - MADISON
UNIVERSITY SPECIAL AND GUEST STUDENT APPLICATION
E-mail: nondegree.student@dcs.wisc.edu

Complete all information to speed processing

A. Program Information

Admit Term: Fall 2003 Academic Program: UNPS 9 Student Group Code: ESCAPE Program Name: Atmospheric and Oceanic Science 509 ESCAPE Course Number: (640) 509 Section 002 Call Number: 80767 Program Coordinator: Rosalyn Pertzborn, Tel: 608-265-4160; rosep@ssec.wisc.edu Instructions: Return this completed application to the address below as soon as possible. Please make note of the call number above as you will need it to register via the Internet after you receive your admission letter.
B. General Information Social Security No. Full name (last) (first) Citizen information U.S. citizen Non-U.S. citizen (country) Permanent home address (street/city/state/zip+4) Mailing address (street/city/state/zip+4) E-Mail address Sex Female Male Are you a veteran? Racial/ethnic heritage (check one)—Optional African American Asian American/Pacific Islander (check one) Cambodian, Laotian, Vietnamese admitted to U.S. after 12/31/75 Other Asian American/Pacific Islander Indicate the last college/university and date last attended Full name of last college/university Have you ever attended UW-Madison? Yes Name change since last enrolled at UW-Madison From (last) (first) Degrees earned BA/BS No
(middle)

Office Use Only Birthdate (M/D/Y)
(middle)

Res {

} Non-Res {

}

Type of visa

Permanent immigrant Since (M/D/Y) /

Since (M/Y) / / / / /

From (M/D/Y) To (M/D/Y) Fax number No American Indian or Alaskan Native Tribe Hispanic/Latino White, NonHispanic city/state If yes, month and year last attended: To (last)
(first) (middle)

date last attended (M/Y)

MA/MS

Ph.D.

Other:

C.

Residence and Employment Information Are you a Wisconsin resident and/or do you claim legal Wisconsin residence for tuition purposes? Yes If yes, complete the following No If no, sign below From (M/D/Y) To (M/D/Y) List all employment and/or activities in the last two years (be specific)) employment/activity city/state

Voting: Where and when did you last vote or register to vote: state Driver’s License: State in which you hold a valid driver’s license: Have you filed a Wisconsin (not Federal) income tax return as a resident? Dependent for Federal taxes of: Self Joint with spouse Father

(M/Y) Date obtained: (M/D/Y) Yes If yes, what years? Mother Other Yes No

High School: Did or will you graduate from a Wisconsin high school or receive a GED in Wisconsin? If yes, month & year of graduation, or when obtained GED: Parental Info: Complete if you have a parent residing in WI, or if your last surviving parent resided in WI.
Name of parent: City/state of residence

•

No

[see Section (c) of Wisc. Stats. 36.27(2)]
Since (M/Y):

Has parent filed a WI State income tax return as a resident for the past 2 years?

Yes

No

US Citizen?

Yes

No

D.

Signature: To be valid, application must be signed and dated.

I certify this information is true and complete; I understand that incorrect/incomplete information may affect admissibility/eligibility to continue.
( ) ( )

signature

date

daytime phone number

home phone number

Send completed application to Office of Space Science Education, SSEC, 1225 W. Dayton, Madison, WI, 53706; fax (608) 262-5974