The Pittsburgh Admission Data form is a foundational document for students embarking on their admission journey to the University of Pittsburgh. It encapsulates crucial personal information and academic intentions, requiring inputs such as the applicant's name, social security number, permanent address, contact information, and citizenship status, as well as parental residency details to ascertain in-state or out-of-state tuition determination. Adding to this, it probes into the applicant's planned residency during their academic tenure, be it on campus, commuting, or off-campus living. Furthermore, it delves into the financial commitment by integrating an enrollment deposit form, which is pivotal for finalizing the admission process. The deposit section calls for detailed payment information, underscoring the transaction's irreversible nature - it is both nonrefundable and nontransferable. This form not only serves as a procedural necessity, it also stands as a testament to the applicant's accuracy and honesty, with a stern reminder that falsification can lead to dismissal. Completing the circle of trust, it includes provisions for the university to seek verification of the provided data from previous educational institutions or employers. The envelopment of all these elements within the form underscores its importance as a cornerstone in the university's admissions protocol, reflecting a blend of personal declaration, financial readiness, and an acknowledgment of institutional policies governing admissions.
| Question | Answer |
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| Form Name | Pittsburgh Admission Data Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 20736 upj admission data form |
ADMISSION DATA FORM
In order to complete the admission process, both the Admission Data Form and Enrollment Deposit Form, including your deposit, must be submitted.
NAME (Last, First, M.I.)
SOCIAL SECURITY NUMBER
PERMANENT ADDRESS (LINE 1)
PERMANENT ADDRESS (LINE 2) |
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CITY |
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STATE |
ZIP CODE |
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AREA CODE, TELEPHONE NUMBER |
AREA CODE, CELL PHONE NUMBER |
PARENT’S |
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FOREIGN ADDRESS (Country, Zip, City, Province)
DATE OF BIRTH (mm/dd/yyyy)
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SEX
FEMALEMALE
PLEASE ANSWER ALL QUESTIONS
Where are you planning to reside? |
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ON CAMPUS (1) |
COMMUTE (2) |
OFF CAMPUS (3) |
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What is your citizenship status? |
U.S. Citizen |
U.S. Immigrant/ |
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Refugee |
Nonimmigrant |
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Permanent Resident Alien |
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Are you a resident of Pennsylvania? |
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No, not a PA Resident |
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If yes, for more than one year or less than one year? |
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Yes, less than one year |
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(Count back from the beginning of the term for which you are enrolling.) |
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Yes, more than one year
Is your father a resident of Pennsylvania?
If yes, for more than one year or less than one year?
(Count back from the beginning of the term for which you are enrolling.)
No, not a PA Resident
Yes, less than one year
Yes, more than one year
Is your mother a resident of Pennsylvania?
If yes, for more than one year or less than one year?
(Count back from the beginning of the term for which you are enrolling.)
No, not a PA Resident
Yes, less than one year
Yes, more than one year
Is your guardian a resident of Pennsylvania?
If yes, for more than one year or less than one year?
(Count back from the beginning of the term for which you are enrolling.)
No, not a PA Resident
Yes, less than one year
Yes, more than one year
I recorded the above. The information given is true and correct. I understand that falsification of any data may result in dismissal. I authorize any employer, educational institution, or agency to release such data as is required by the University to verify any of the above information. By signing below, I also authorize the University of Pittsburgh to request and, my high school and/or testing agencies to release, any academic information or college entrance test results needed to make my admissions file complete.
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Student’s Signature |
DO NOT WRITE IN SHADED AREA.
ENROLLMENT DEPOSIT FORM
STUDENT’S NAME (Last, First, M.I.) |
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SOCIAL SECURITY NUMBER |
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DATE RECEIVED (mm/dd/yy) |
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DEPARTMENT NAME |
UNIVERSITY TELEPHONE EXT. |
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CREDIT CARD INFORMATION |
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Office of Admissions |
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See instructions on back. |
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ENROLLMENT DEPOSIT |
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AMOUNT |
DEPOSIT FOR |
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MasterCard |
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Visa |
A |
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(NONREFUNDABLE/NONTRANSFERABLE) |
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TERM |
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CREDIT CARD NUMBER |
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TOTAL AMOUNT RECEIVED IN |
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$100.00 |
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Check |
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MC |
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PRINT NAME AS SHOWN ON CARD |
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C |
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AMOUNT CHARGED |
EXPIRATION DATE (mm/yy) |
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Money Order |
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Visa |
$ |
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$ |
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INSTRUCTIONS
ACheck MasterCard or Visa.
BPrint you credit card number in the appropriate box.
CPrint cardholder’s name.
DEnter the amount to be charged.
EEnter card’s expiration date.
REMEMBER
Your bank credit card limit cannot be exceeded. If you are in doubt regarding the limit, contact your bank before completing this form.
Before the University can accept your charge, it must receive authorization from the MasterCard or Visa authorization center. If this center declines to accept your charge, we will so indicate on the deposit receipt and will return it and any other documents to you.
If your charge is declined, contact your bank for the reason. The authorization center will not give the University the reason for its refusal to authorize the charge.
The University of Pittsburgh is an affirmative action, equal opportunity institution.