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UNI Continuing Education Enrollment
Enrollment Form
Items marked with an asterisk ( * ) are required to process your registration. Please use the 'Tab' key after entering your information to move from box to box.

1.

Social Security Number:  *
- -     Re-Enter SSN:  * - -
OR  
UNI Student Number / UID: *
 
  I do not have a Social Security Number or I do not wish to share this information.
 
Tuition / Fee:   
(View Tuition Information)
Class Location:   
Dates:
 
Charge my U-Bill (U-Bill will be sent electronically to your UNI email account).
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, American Express) 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:
  Country: 
 
 
Street 1  *
 
Street 2
 
City  * State/Province/Territory *   County (for Iowa only) Postal/Zip Code  *
  -
 
 
  Phone:
 
       
Home Phone Number * Mobile Phone Number Work Phone Number
 
  Residency:
  Are you a United States citizen?  * Yes   No
 
  What is your country of citizenship? 
 
  Do you consider yourself an Iowa resident?  * Yes   No
 
  Dates you have lived in Iowa:
    Never
  From birth to present
 From:      To:  
 

4.

Legal Sex (based on official identification):  *  Female   Male
  Gender (self-identified, may be different than legal sex):   
 

5.

Birthdate:  *   
 

6.

From what high school did you graduate?
 
High school name:
High school city:   High school state/province/territory:
When?
 

7.

For what courses do you wish to enroll?     View course information (will open in a new window)
 
Class Nbr * Title * Units of
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:   For students who wish to receive graduate credit, verification of degree(s) is required. The University of Northern Iowa will attempt to verify degree(s). If we are unable to obtain verification we will request students contact the institution(s) that awarded the degree(s) (BA or higher) to have verification sent directly to UNI. Failure to provide such verification will cause 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:
Country:
State/Province/Territory:
Dates Attended From:
Dates Attended To:
Degree Expected/Received:
(AA,BA,etc.)
 
 
College or University Name:
Location:
Country:
State/Province/Territory:
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
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
 

14.

Email Address:  *  
  Continuing & Distance Education will use this email to send important information about your course and next steps. Please provide an email you check regularly.
 

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.

I acknowledge that I am responsible for my university bill (u-bill) and that I have read and understand the U-bill Terms and Conditions of Financial Responsibility.
Please indicate your affirmation by checking this box:  *
 

17.

Enter the text exactly as it appears in the picture below.
 
 

18.

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: 2014-10-31 11:32:25 -0500 (Fri, 31 Oct 2014) $ $Revision: 50474 $