Fillable CCSU GRADUATE RE-ACTIVATION REQUEST FORM

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CCSU GRADUATE RE-ACTIVATION REQUEST FORM

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INSTRUCTIONS: Please complete this form to Re-activate a Graduate Admissions file that has been inactive or withdrawn for two (2) or fewer years and you now wish to return to finish your original or another graduate program. NO ADDITIONAL APPLICATION FEE IS Graduate Recruitment and Admissions Office Central CT State Uni versity Henry Barnard Ha ll RM 102 1615 Stanley Stre et New Britain , CT 06051 - 4010 GRADUATE RE-ACTIV ATION REQUEST FORM FOR OFFICE USE ONLY : Information Request ed: __________ _________ ________________ _______________ ________ ________________ _______________ ________ ________________ _______________ ________ CPA __ _______ ________________ __________ Degree__________ _______________ ________ Progr am _________ _______________ ________ Specialization___ ____________________ ____ Action/Date_____ _____________ ___________ STUDENTS PREVIO USLY ACCEPT ED INTO A GR ADUATE PRO GRAM: Original date of admission for gr aduate study: Fall Spring Summer Year ______ __ ____ Did you begin taking classes : Yes No If yes, date of last attendanc e: Fall Spring Summer Year ______ ______ STUDENTS WHO PREVIOUSLY APPLI ED TO A GRADUATE PRO GRAM BUT WERE WITHDRAWN OR NOT ACCEPT ED: Original date of application: Fall Spring Summer Year _______ __ ___ RE -ACTIVATION RE QUEST FOR: Fall Spring Summ er (avail able for se lected progra ms) Year ___________ Full-time Part-time PROGRAM SOU GHT: New Program Prior program (no change i n degree o r major)

Degree___ ____________ ______________ __ Major_________ ____________ _________________ ____________ ____

Specialization (if a pplicable)_________ _________________ _________ __

NAME :_________ ________________ ________________ _______________ ______________ ________________ _________

(Last) (First) (Middle)

FORMER NAME/OTH ER NAMES :_ _____________ ________________ _____________ _______________ _____________ _

CCSU ID#: _______ _______________ ________________ __ SS#:( optiona l)______________ _________________ ________

ADDRESS: _______ _________________ ________________ ____________ ________________ ______________ __________

CITY: ________ __ _____________ ___________________ __ STATE : ___________ ___________ ZIP :___ _____________ __ __

COUNTRY: _______ ______________ ______________ ____ EMAIL:____ __ ___________________ ____________ _______ __

PHONE :(home)___ _____________ __________(cell)_ ______________ _________(work)_ __________________ _________

Are you a citizen of the United States ? Yes No If no, what is yo ur country of Citizenship? ______ __ __________

Are you a legal re sident of Con necticut? Yes No If yes, indicate years in C onnecticut ___________ __ __________

If non-c itizen check appropriate box : F1 or F2 student visa Eli gible non-citizen Other visa

Permanent r esident, list alien r egistration num ber ____________ _____________ ________________ ______________

Are you a U.S. Vet eran? Yes No Have you taken courses at other institutions since your initial ap plication to C CSU? Yes No

If yes, please list institutions. An offic ial transcript must be sent to the Graduate Recruit ment and Admissi ons Office from

each college atte nded. Consult the Gr aduate Ca talog for Transfer Cr edit Polices. Institution Name Location ( City/ State) Dates Attended Degree Awarded

________________ _______________ ______________ ________________ _____________ _____________ _____________ _

________________ _______________ ______________ ________________ _____________ _____________ ______________

_____________________ __________ ________________ _______________ ______________ ________________ _________

Student Signatur e _______________ ______________ ________________ _____________ __________ Date___ ________ __

Your signature verifie s the correctness an d accuracy of the inform ation you have prov ided on this form. Mi sleading informati on may result in non -admission or d ismissal for th e program.