Anticipated Start Date:

Plan to attend at this location:

      Fayette Campus
      Des Moines 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.