Fill and Sign the Consent Permanent Form

University of Mobile Application for Re-Admission 5735 College Parkway • Mobile, Alabama 36613-2842 • (251) 442-2273 • 1-800-WIN-RAMS (1-800-946-7267) adminfo@mail.umobile.edu Personal Information Name_____________________________________________________________________________________________________________ Mr. Mrs. Miss Ms. First Middle Last/Family Preferred Name/Nickname ________________________________________Former Last Name (If any) ____________________________________________ Name as Recorded on Original Application: ________________________________________________________Date of Birth: _________________________ Social Security Number ___________________________________ Applying for Entry in Year __________________ Semester: Fall Spring Summer County __________________________________ Home Phone __________________________________ Work Phone _________________________________ Cell Phone_____________________________________________E-mail ________________________________________________________________________ Address ___________________________________________ City _________________________________ State ______ Zip/Postal Code__________________ Are You a U.S. Citizen? Yes No I Plan to enter (Check One): ____Traditional Undergraduate Program ____Center for Adult Programs Last term attended: _______________________________________________ Semester/Year Educational Information List All Colleges You Previously Attended. Do Not Use Abbreviations. Failure to Give Full and Complete Information May Result in Loss of Credit or Dismissal From the University of Mobile. (Attach separate sheet if necessary) ________________________________________________________________________________________________________________________ School/State Hours Earned Dates Attended Degree Received ________________________________________________________________________________________________________________________ School/State Hours Earned Dates Attended Degree Received ________________________________________________________________________________________________________________________ School/State Hours Earned Dates Attended Degree Received Have You Ever Been Placed on Probation, Suspended or Dismissed From Any School? Yes No If Yes, Please Explain:_________________________________________________________________________________________________________________ Do you already have a degree?  Yes  No If so, state type of degree received___________________________________________________________ Are you seeking teacher certification?  Yes  No Previous Advisor’s Name: ___________________________________________________________________________________________________________ Do you wish to be assigned a new advisor?  Yes  No If so, indicate name of new advisor_______________________________________________ Are you planning to live in the residential halls?  Yes  No PLEASE INDICATE YOUR MAJOR: Accounting Accounting-Corporate/Non-Profit Accounting-Public Accounting (4-Yr) Accounting-Integrated Program (5-Yr MBA) Art Athletic Training Biology Business Administration Business Administration-Finance Business Administration-Global Business Business Administration-Management Business Administration-Marketing Church Music Communication Communication-Advertising/Public Relations Communication-Business Communication Communication-Health Care Communication Communication-Print/Broadcasting Journalism Computer Information Systems Computer Information Systems-Information Security Education-Early Childhood Education-Elementary Education Education-High School Certification English Environmental Management General Studies History Human Performance & Exercise Science Humanities Marine Science Mathematics Music Musical Theatre Associate Degree In Nursing Bachelor Degree In Nursing Pre-Engineering-Mathematics Pre-Dentistry-Biology Pre-Medicine-Biology Pre-Pharmacy-Biology Pre-Physical Therapy - HPES Pre-Veterinary Medicine-Biology Political Science Political Science-Pre-Law Psychology Social Science Sociology Theology Theology-Missions Theology-Pastoral Ministry Theology-Youth Ministry Vocal Performance Worship Leadership MAJORS AVAILABLE FOR THE CENTER FOR ADULT PROGRAMS Bachelor of Business Administration Biblical Studies Early Childhood or Elementary Education Leadership and Cultural Studies Bachelor of Science in Nursing (RN to BSN for Career Nurses) Financial Aid and Admission Statements (This Section Must Be Completed and Signed) – Please Read Carefully– AUTHORIZATION: The undersigned does hereby certify to the best of his/her knowledge; the information given in this application is correct and complete. Further, it is agreed the University has permission to verify any or all information given herein. It is also agreed the University shall be supplied copies of U.S. and State Income Tax Reports upon request. Any significant change in financial status will be reported to the University. STATEMENT OF EDUCATIONAL PURPOSE / REGISTRATION COMPLIANCE To the applicant for Federal Student Financial Assistance: Section 484 of the Higher Education Act (20 U.S.C. 1091) requires that each recipient of a grant, loan or loan guarantee under the Pell Grant, Supplemental Educational Opportunity Grant, National Direct Student Loan, Guaranteed/Federal Insured Student Loan or Auxiliary Loan programs file a statement of education purpose stating that money attributable to such a grant, loan or loan guarantee will be used solely for expenses related to attendance or continued attendance at an institution of higher education. The amount of compensation received from employment under the College Work-Study Program is based on a student’s need for such funds to attend an institution of higher education; thus, earnings from that program must be used solely for expenses related to attendance at such an institution. A student participating in the College Work-Study Program shall file a statement to that effect. Furthermore it is a federal law (Public Law 97-252; Section 1113 of the Fiscal Year 1983 Defense Department Authorization ACT, 48FR15578-84) that a student is ineligible for student financial assistance provided through programs established under Title IV of the Higher Educational Act if the student is required to have registered with Selective Service and fails to do so. CHECK THE STATEMENTS BELOW (Items 1-8), SIGN AND DATE 1. _____ I CERTIFY that the information provided to the University of Mobile on my application(s) for financial aid is correct and complete. 2. _____ I CERTIFY that the University of Mobile has permission to verify any information used in determining my eligibility for financial aid. 3. _____ I CERTIFY that any significant change in financial status will be reported in writing to the University of Mobile Office of Financial Aid. 4. _____ I CERTIFY that I am not required to be registered with Selective Service, because (check one reason): ____ I am female ____ I have not reached my 18th birthday ____ I was born before 1960 ____ I am in the armed services on active duty (NOTE: Members of the reserves and National Guard are not considered on active duty.) ____ I am a permanent resident of the Trust Territory of the Pacific Islands or Northern Marine Islands. 5. _____ I CERTIFY that I am registered with Selective Service. 6. _____ I CERTIFY that I will use any funds I receive under the Pell Grant, Supplemental Educational Opportunity Grant, College Work-Study Program, Guaranteed Student Loan, Alternative Loan, PLUS Loan, Alabama Student Program, Alabama Student Assistance Program, Student Incentive Grant Programs solely for expenses connected with attendance at the University of Mobile. 7. _____ I CERTIFY that I am not in default on any loan made under the National Direct/Defense Student Loan, Guaranteed Student Loan, Nursing Loan, Alternative Loan, Parent Loan Program (Title IV, HEA loan) for attendance at any institution. 8. _____ I CERTIFY that I do not owe a refund on a grant received under the Pell Grant, Supplemental Opportunity Grant, Alabama Student Grant, Alabama Student Assistance Grant or State Student Incentive Program (Title IV, HEA grant) for attendance at any institution. PLEASE REFER TO THE CATALOG FOR ALL ADMISSION AND FINANCIAL AID REQUIREMENTS: By signing below: • I am fully aware that the University of Mobile expects a high standard of academic performance and personal conduct from each student. I understand and agree with these principles and, if accepted for admission, I promise to abide by all rules and regulations of the University of Mobile. • I understand that if any information on this form is found to be inaccurate or incomplete, it will be sufficient cause for my rejection or dismissal. • If I choose to enroll, I understand it is my responsibility to read all University publications, including but not limited to the University of Mobile catalog and Student Handbook. • I agree to conduct myself in accordance with the high standards of the University of Mobile and the established residence hall policies as set forth in the University of Mobile catalog, Student Handbook and other publications. Student Signature: _______________________________________________________________________Date: ________________________________________