Usm Readmission Form – Fill Out and Use This PDF

Reactivation/Readmission Application for Undergraduate Admission

A. Reactivation of Application

❑You applied to USM within the last year but did not enroll in classes as a degree (matriculated) student

B. Readmission

❑You received an undergraduate degree from USM and are pursuing a second undergraduate degree

❑You began your studies at USM as a degree (matriculated) student more than ten years ago but did not graduate

Matriculated degree candidates maintain their matriculation status for ten calendar years from the first semester of attendance at USM. If, for any reason other than dismissal from the University, a student does not register for any length of time during that ten-year period and then resumes registration, no readmission decision is necessary. If, however, a student wishes to resume studies as a degree candidate after the ten-year period has elapsed, she or he needs to apply for readmission using this application form.

If none of these categories apply, use a standard application for admission. You can request a standard application by calling (207) 780-5670 or 1-800-800-4USM x5670; TTY (207) 780-5646, or by accessing it on our Web site: usm.maine.edu/admit

I am applying for: September 20_____ January 20_____ I will attend: ❑ full-time ❑ part-time

Print name in full ____________________________________________________________________________________________

Last	First	Middle
Preferred first name ________________________________________________		Gender (optional): ❑ female ❑ male

Social Security Number* ___________ – ________–__________ Name used on previous records _________________________

(e.g., maiden name)

*We need your SSN to process your financial aid. If not provided on your admission application, you will be required to provide it at a later date.

Permanent mailing address:

___________________________________________________________________________________________________________

StreetCityState/ProvinceZip/Postal Code Country

E-mail address _________________________________________ City/State/Prov. of legal residence ________________________

Home phone ( ______ ) ______________________________ Preferred phone ( _____ ) _________________________________

Are you a legal resident* of Maine? ❑ Yes ❑ No If yes, date you became a legal resident ______ /______ /______.

*Lived in Maine for 12 consecutive months immediately prior to enrollment, for purposes other than education. Proof may be required

Current mailing address: Mailing address end date: ____ /_____ /_____

___________________________________________________________________________________________________________

Street	City	State/Province	Zip/Postal Code	Country
Date of birth (mm/dd/yy) _______	Country of birth _______________	Are you a U.S. citizen?	❑ Yes ❑ No
Country of citizenship ____________________________

If you are a US Permanent Resident, indicate alien registration number on your Permanent Resident Card A# ___________________

(Optional) Language spoken at home ______________________________ Are you of Franco-American heritage? ❑ Yes ❑ No

(Optional) Please indicate if you are Hispanic/Latino: ❑ Yes ❑ No

(Optional) Please select one or more of the following racial categories to describe yourself:

❑American Indian or Alaska Native ❑ Asian ❑ Black or African-American ❑ Native Hawaiian or other Pacific Islander ❑ White

If planning to attend classes off campus, indicate site/center _________________________________________________________ _

Intended academic major? First choice ______________________________________________________________________

Second choice ____________________________________________________________________

Housing plans: ❑ Residence Hall ❑ Off campus

HIGH SCHOOL INFORMATION: Please indicate all high schools and postgraduate high schools you have attended.

Complete School Name	City	State	Zip	From Mo/Yr	To Mo/Yr	Graduation Date
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Did you receive your high school equivalency diploma through the GED examination? ❑ Yes					❑ No Month/Year awarded___ /____

COLLEGE INFORMATION: University policy requires full disclosure with regard to all colleges and other post-secondary schools attended. Please list in the order of enrollment, with most recent college first including USM and all University of Maine System cam- puses. Failure to disclose previous enrollment may have consequence as serious as revocation of the offers of admission and financial aid.

Complete College Name	City	State Zip	Full- or	From	To	Graduation	# Credits
			Part-time	Mo/Yr	Mo/Yr	Date	Attempted
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

0 0 __ __ __ __ College Board Code for most recent college attended. College credit hours attempted ___ Degrees earned ___

Have you ever been found responsible for a disciplinary violation at an educational institution you have attended from ninth grade (or the international equivalent) forward, whether related to academic misconduct or behavioral misconduct, that resulted in your suspen- sion, removal, dismissal, or expulsion from the institution? ❑ Yes ❑ No

Have you ever been convicted of a misdemeanor, felony or other crime, or adjudicated of committing a juvenile crime? ❑ Yes ❑ No

If you answered YES to either or both questions above, please attach a separate sheet of paper that gives the approximate date of each incident and explains the circumstances. Please note: Applicants are expected to immediately notify the Office of Undergrauate Admis- sion should there be any changes in their application, including disciplinary history.

Essay/Personal Statement: Please attach a personal statement explaining your reason for reactivation/readmission. You should also include a resume, any work experience, volunteer activities, and/or community service performed since applying to USM.

My signature below verifies that the information I have reported on this application is complete and factually correct. If I am a transfer applicant who has attended another campus in the University of Maine System, I give permission for the Office of Undergraduate Admission to request my academic record electronically.

Applicant’s Signature _________________________________________________________________ Date_______________

Please send application and all supporting documents to:	University of Maine System
	Application Processing Center
	PO Box 412
	Bangor, ME 04402-0412

Application materials received by the Office of Undergraduate Admission and the Application Processing Center become the property of the University of Maine Sys- tem and the University of Southern Maine. University policy requires these records be retained and not returned to the applicant nor forwarded or released to a third party. The Office of Undergraduate Admission reserves the right to require additional information in order to make an admission decision; you will be contacted if any additional information is needed. Applicants should be aware that the University of Southern Maine complies with Title IX of the Education Amendments (1972), Title VI of the Civil Rights Act (1964), and Section 504 of the Rehabilitation Act (1973).

8/2011