Graduate Readmit/Reenrollment Request Form

Name

First Name

Middle Name

Last Name

Preferred Name

Former Name(s)

Address

Permanent Address

Country

Street

City

Region

Postal Code

Contact Information

Email Address

Home Phone Number

Cell Phone Number

Biographical/Citizenship Information

Sex Assigned at Birth

Gender Identity

Birthdate

SSN

Primary Citizenship

Are you a US Permanent Resident?

Yes

Permanent Resident Card Number

Date of Established Residency in Ohio

Race/Ethnicity

Colleges and universities are asked by many groups, including the federal government, accrediting associations, college guides, and newspapers, to describe the ethnic/racial backgrounds of their students and employees. In order to respond to these requests, we ask you to answer the following two questions.

Are you Hispanic or Latino?

Yes

Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:

Enrollment Information

Reenrollment Term

Academic Program

Community Integrity

The University of Akron is committed to maintaining a university environment characterized by safety, respect, integrity and inclusion. As a condition of enrollment, all University of Akron students must respond to the Community Integrity questions upon seeking enrollment at UA. Answering yes to either question below does not automatically bar you from enrollment. The University of Akron reviews each case holistically and seeks to understand the context of each student's situation.

Have you ever been dismissed/expelled for any disciplinary or academic reason from any school (including The University of Akron) or is an academic dismissal/expulsion or disciplinary charge from any such institution currently pending against you?

Yes

Have you ever been convicted of a criminal offense (felony, misdemeanor or juvenile offense) other than a minor traffic violation, or is any such charge currently pending against you?

Yes

The University will need additional information before you can proceed with enrollment. Please provide detailed information about these incidents as well as your permission to obtain additional information directly from the police, court records, or individuals involved.

In order to obtain this information directly, we may need your written permission. If this Supplemental Information Form is not submitted within 30 days, we will presume that you do not grant permission to pursue records, and that you no longer seek enrollment at The University of Akron.

Disciplinary History

Please include all dismissals/expulsions and any pending charges from any school. Failure to include a complete record or falsifying answers may disqualify an applicant from enrollment at UA.

Charges

Violations found responsible for

Penalties

Date of incident

School where incident occurred

Please explain the details and circumstances surrounding the incident.

Please describe the nature of the offense, and what, if any, rehabilitation efforts you have undertaken and/or what you have learned from the experience.

Criminal History

Please include all convictions and any pending criminal charges. Failure to include a complete record or falsifying answers may disqualify an applicant from enrollment at UA.

Offense you were charged with

Date of conviction

Date of charge, if still pending

Arresting agency

Court in which charges were heard

Case number assigned by court

Sentence/fine imposed

Name and contact information of any parole or probation officer or counselor assigned to your case

Please explain the details and circumstances surrounding the incident.

Please describe the nature of the offense, and what, if any, rehabilitation efforts you have undertaken and/or what you learned from the experience.

I certify that the information herein is complete and accurate to the best of my knowledge. I hereby grant permission to The University of Akron to seek and to exchange any information with the academic institutions that I have attended. I further authorize any such academic institution to release any records or confidential information concerning me to The University of Akron. I agree to abide by the rules set forth in the University Bulletin. I understand that The University of Akron maintains a system of records which has been in existence and operating since 1968 and which utilized the Social Security Number until the fall of 2001 for the purposes of verifying the identity of students.

Please enter your full name to verify.