Complete Your Application

Page 1

Name and Contact Information

First Name

Middle Name

Last Name

Preferred Name

Former Last Name

Gender

Cell Phone

Home Phone

Email

Verify Email

Birthdate

Social Security Number (SSN)

Your social security number is sensitive personal information which may be used to complete and process your application. We have established a secure Internet connection for your submission, and your social security number will be encrypted while in transit, but we cannot guarantee protection of your social security number from disclosure. By continuing with submission of your application and voluntarily disclosing your social security number, you assume the inherent risks of doing so and consent to transmission of your social security number over the Internet.

Page 2

Address Information

Permanent Address Type

Street Address

City

State

Zip/Postal Code

Province/Region/Territory

Country

Page 3

Citizenship Information

Citizenship Status

What is your country of citizenship?

What is your Alien Registration Number?

A-Number or Green Card Number

What is your Visa type?

What is your city of birth?

What is your country of birth?

Demographic Information

If you wish to be identified with a particular ethnic group, please select the choice that most accurately describes your heritage. Listed categories reflect federal reporting standards. No information you provide will be used in a discriminatory manner.

Are you Hispanic or Latino?

YesNo

Page 4

Referral Information

How did you find out about us?

Other

Select your Rockford University approved agent:

Your agent:

Do you have any relatives who are attending or have attended Rockford University?

YesNoThis includes Rockford College.

Legacy Information

First Name

Last Name

Relationship

Graduation Year

Employer Information

Employer

Please list your employer here

Position

Page 5

Academic Information

Program choice

Expected Start Term

Semester Options

Fall semester begins mid-August
Spring Semester begins mid-January
Summer Semester begin late-May

Semester Start Options

Spring 1 begins mid-January
Spring 2 begins mid-March

Summer 1 begins late May
Summer 2 begins late June

Fall 1 begins mid August
Fall 2 begins late October

Do you intend to be full-time or part-time?

Full-TimePart-TimeUnsure

Do you plan to live on-campus or off-campus?

On-CampusOff-CampusUnsure

MBA Concentration

MAT Professional Educator License of choice

MAT Middle Grades Endorsement of choice

MAT Secondary Education Endorsement of choice

MAT K-12 Endorsement of choice

M.Ed Endorsement of choice:

I hold a PEL with and endorsement in:

Endorsement of choice:

Business Certificate of choice:

Have you applied to Rockford University in the past?

YesNo

Page 7

Submit

Have you ever been convicted of a felony?

YesNo

Please explain.

Have you ever been suspended from any school?

YesNo

Please explain.

Certification

I certify that the information on this application is complete and correct, and I understand that the submission of false information is grounds for denial of my application, withdrawal of any offer of acceptance, cancellation of enrollment, or any appropriate disciplinary action. I authorize the University to verify the information I have provided with all the schools I have attended. I agree to notify the proper officials of the institution of any changes in the information provided. I give my high school(s) and college(s) permission to send my official transcript(s) directly to Rockford University.

I Certify

Signature

Please enter your full name in the signature box, verifying that you have completed the application.

Submission Date