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UNI Continuing Education Enrollment
Enrollment Form
Items marked with an asterisk ( * ) are required to process your registation. Please use the 'Tab' key after entering your information to move from box to box.
1.
Social Security Number:  *
- -     Re-Enter SSN:  * - -
OR     
Student Number / UID:  *
 
Tuition / Fee:   
Class Location:   
Dates:
 
Please indicate if you have applied for financial aid through UNI to ensure the charge is applied to your university account at the appropriate time.
Bill me
Invoice (check this option ONLY if your tuition will be paid directly to UNI by a school, business or other institution). Contact Continuing and Distance Education with details.
  Payment by credit card (Mastercard, VISA, Discover) may be made by calling 1-800-772-1746,
Monday through Friday, 8:00 a.m. - 4:30 p.m. CST.

You may also print a copy of this form and submit by postal mail.
 

2. Enter name in full:
 
Last Name  * First Name  * Middle Name Maiden Name
 
  If previously enrolled at UNI or elsewhere under another name, enter that name:
 
Last Name First Name Middle Name
 

3. Home address or present mailing address:
 
Street 1  *
 
Street 2
 
  -
City  * County (for Iowa only)   State  * Zip Code  *
 
  Country
 
 
 
Current Phone Number *   Permanent Phone Number
 
Work Phone Number   International Phone Number
 

4. Gender:  *    Female    Male   
 

5. Birthdate:  *   
 

6. From what high school did you graduate?
 
High school name:
High school city:   High school state:
When?
 

7. For what courses do you wish to enroll?      View course information (will open in a new window)
 
Class Nbr * Title * Hours *
Credit
Instructor
 

8. I am enrolling for:  *    Undergraduate Credit    Graduate Credit   
 

9. Have you been enrolled previously or earned credit at UNI?  *    Yes    No   
 
If Yes, when?         Degree? (Earned or Pursued)  
 

10. College Record:   List colleges you have attended (other than UNI).
  Notice:   All students who are new to the University of Northern Iowa and are wishing to receive graduate credit must provide verification of each degree they have earned, unless the degree was obtained from the University of Northern Iowa. Failure to provide such verification will cause the studentís classification to be changed to undergraduate status.
 
Authorization:   By electronically signing below, I hereby authorize, without reservation, any party or agency contacted by the University of Northern Iowa, any of its agents, or any entity employed by the University of Northern Iowa for such purposes to furnish the above-mentioned information.
 
 
 
College or University Name:
City:
State:
Country:
Dates Attended From:
Dates Attended To:
Degree Expected/Received:
(AA,BA,etc.)
 
 
College or University Name:
Location:
State:
Country:
Dates Attended From:
Dates Attended To:
Degree Expected/Received:
(AA,BA,etc.)
 

11. Will you use this course to meet UNI degree requirements?  *    Yes    No   
  If Yes, which degree?
 

12. Are you claiming Veteran's Administration Educational Benefits?  *    Yes    No   
 

13. The U.S Office of Education, in compliance with the Civil Rights Act of 1964, requires institutions of higher education to compile and report enrollment data on students, broken down as to racial ethnic composition. These data are for statistical purposes only and will be treated confidentially.   
 
  Do you consider yourself to be of Hispanic/Latino/Spanish origin?  Yes No  
 
  Please select one or more of the following racial categories to describe yourself:
 
American Indian or Alaska Native  Black or African American
Asian  Native Hawaiian or other Pacific Islander
White    
 

14. Email Address:  *  
 

15.
I certify that the information provided in this enrollment form is accurate. By checking the box below, I affirm that I understand the University of Northern Iowa reserves the right to restrict enrollment and to cancel courses that do not meet minimum enrollment requirements. I understand that classes may be recorded because of weather or technical difficulties.
Please indicate your affirmation by checking this box:  *
 

16. As a result of clicking below, your information will be submitted for approval. After submission you will have an opportunity to view your completed form and print a copy.
 
 
 
 
Please note that your enrollment request will be reviewed to ensure eligibility to register for coursework. This process ordinarily takes two to three days, after which the course(s) will be added to your schedule within your Student Center.
 
The University of Northern Iowa requests the information included in this form for the purposes of enrollment. No persons outside the University are routinely provided this information, except for items of directory information such as name and local address. Release of any information is governed by Board of Regents rules and applicable state and federal statutes.
 
Maintained by Information Technology Services.
Send questions or comments to UNI Continuing Education and Special Programs.
$Date: 2009-08-17 11:32:25 -0500 (Mon, 17 Aug 2009) $ $Revision: 21690 $