Anticipated Start Date:

Plan to attend at this location:

Fayette Campus
Des Moines Center
Cedar Rapids Center

Last Name:

First Name: Middle/Maiden Name:

Mailing Address:

City: State: ZIP:

Home Phone: Work Phone:

Cell Phone: Fax Number:

E-Mail Address:

Do you plan to be a part time or full time student? Part Time Full Time

Do you plan to apply for Financial Aid? Yes No

United States Citizen? Yes No

If "No," where is your citizenship?

Social Security Number:

Date of Birth (Month/Day/Year):

Employer:

List all colleges/universities attended and their location:
College/University State Dates Attended Degree/Credits Completed

Do you hold a Registered Nursing license? Yes No

If "Yes," in what state(s)? License:

How did you first learn about Upper Iowa University?

Alumni
Colleague
Advertising Materials
Word of Mouth
Other (please specifiy)

Race / Ethnicity (OPTIONAL)

African American / Black Alaskan Native Asian
Hispanic / Latino / Latina Native American
Pacific Islander / Hawaiian Native White / Caucasian
Other (please specify):

By submitting this form, I indicate that the information in my application is complete, factually correct and honestly presented.