Non-Degree Application

I am applying as a: *

Academic Program

Admit Type

Student Type

App Submitted Date

Name

Prefix

First Name

Middle Name

Last Name

Suffix

Nickname/Preferred First Name

Maiden Name/Other Last Names Used

Contact Information

Permanent Address

Country

Street

City

Region

Postal Code

Mailing Address (if different than Permanent Address)

Country

Street

City

Region

Postal Code

Email Address

Mobile Phone

Home Phone

Biographical Information

Sex

Birthdate

Primary Citizenship

Secondary Citizenship

Permanent Resident

Yes

No

Social Security Number

Hispanic

Yes

No

Coursework Academic Level

Select the term in which you'd like to take coursework

What level of coursework will you be taking?

Other Required Information

I am applying for the UB Language Academy.

UB Language Academy Educational Partnership Field Population - Hidden

How did you hear about us?

If other, please specify

Have you ever been sanctioned for disciplinary misconduct at any higher education institution for academic or behavioral violations? For the purpose of this question, “sanctioned” includes but is not limited to: dismissal, removal, expulsion, probation, or suspension.

Yes

No

If yes: Please explain the incident(s).

Have you ever been charged or convicted of a felony, misdemeanor, or any other crime?

Yes

No

If yes: explain the incident, state the charge(s) you were convicted of, and provide documentation explaining the nature of the offense (sentencing order, plea agreement, etc.).

Signature

Conditions of Non-degree Enrollment

Registration as a non-degree student is on a space-available basis and not all courses are open to non-degree student.
Non-degree students are responsible for meeting course prerequisites; transcripts may be required as proof.
A maximum of twelve credits taken as a non-degree student may be applied towards a degree at the University of Bridgeport.
You may register for subsequent semesters as a non-degree student based on your academic performance and good standing in the university.
Financial aid is not available to non-degree students.
Enrollment as a non-degree student does not guarantee or imply admission to the University.

Signature

My signature below indicates that all the information contained in this enrollment form is complete and correct. I am aware that any falsification in the completion of this enrollment form, either by error or omission, may result in my being denied enrollment by the University of Bridgeport or may result in disciplinary action.

Signature

Signature Date