University of Wisconsin-Stout Undergraduate Reentry/Special Application
Social Security Number*___________________________ Student ID Number*________________ E-Mail Address ____________________
Demographics
Last Name
First
Middle
Birthdate:
Home Address
Street and No.
City
Maiden (Prior)
Work Phone
State/Zip
Home Phone
Please Print
_________________________
Mo.
County
Semester/Term you plan to enter: (check one)  Fall/Year ______  Spring/Year ______  Summer/Year ______
Applying to complete:  First Degree  Second Degree  Certification Name of degree program: _____________________________
 Special Student  Graduate Student Taking Undergraduate Deficiencies
Reason for absence from UW-Stout _______________________________________________________________________________________
Gender:
 Male
 Female
Ethnic Background:
 American Indian or Alaskan Native
 Asian or Pacific Islander
 Cambodian, Laotian or Vietnamese
admitted to U.S. after 12/31/75
 Other Asian or Pacific Islander
Residence Data
The following data is needed to determine if you should be charged in-state or out-of-state tuition. Criteria for determining residence status are defined by state law. A copy of the Wisconsin Statutes is available
upon request. Please Note: It is your responsibility to register correctly, as a resident or non-resident, under the law.
 Black, non-Hispanic
 Hispanic/Latino
 White, non-Hispanic
Wisconsin resident?  Yes  No
If resident, how long have you lived in Wisconsin? Since ____ /____ (Month/Year)
Month/Year
Indicate the dates you have lived at your present address
Year
U.S. Veteran:  Yes  No
* Use of your social security number is voluntary.
When was the last year you filed Wisconsin income tax? 20 ___ (Year)
Day
Month/Year
From: _________ To: ________
List former addresses (street, city, state, country) within the last two years:
________________________________________________________________________________________
From: _________ To: ________
________________________________________________________________________________________
From: _________ To: ________
Citizenship: If changed since last attendance, check one:
 Citizen
 Non-resident Alien
 Permanent Resident
Occupations and Activities During the Last Two Years
Alien Registration Number
Occupation, activity, school or employer and address:
________________________________________________________________________________________
________________________________________________________________________________________
Parent’s name
From: _________ To: ________
Country of Citizenship:_________________
From: _________ To: ________
Place of Birth:
___________________________________________________________
Parent’s Address (last 2 years)
___________________________________________________________
City
From: _________ To: ________
Have you, your spouse or parent(s) recently moved to Wisconsin to accept permanent full-time employment?  Yes  No
State
Country
Do you claim legal Wisconsin residence for tuition purposes?  Yes  No
Education History
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and/or invalidation of credits or degrees earned.
Name
Location
Dates
Degree or diploma and
date awarded (Month/Year)
High School:
__________________________________________________________________
College(s):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
For Office Use Only
Trs. GPA ________
Rank ____________
Original Term _____ Last Term _____ Major _____
Trs.Credits ______
Pctile. ___________
R NR Frn Dismissal Probation
Trs. Cmpl. 1 3 5
ACT/SAT __________
Cum Credits _____ GPA _____ Trs. Credits ____
GS PROB COND PROV DENY ____ WL ___
Restrictions ____________________________________ Date ____________ Class ___ Cat ____ Crit____
Signature Required
I certify that the information in the application is true and complete to the best of my knowledge and I understand that inaccurate information may affect my enrollment or financial aid status. If I enroll at UW-Stout, I expect to be subject to its rules and regulations.
__________________________________________________________________
Signature
For instructions on completing this form, see back.
Date
Instructions: Reentry/Special Application
Use the Reentry/Special
Application if you:
• PreviouslyattendedUW-Stoutasanundergraduateandhavebeenoutofclassesforone
semesterormore(excluding summer sessions)
• Wanttoapplyasacertificationornon-degreecandidate.
Instructions:
1. Complete the application. Be sure to sign the
form.
2. Mailordeliverthesignedapplicationto:
Admissions Office
212 Millennium Hall
University of Wisconsin-Stout
Menomonie, WI 54751-0790
Previous Special Students:
Ifyounowwishtobecomeadegree-seekingstudent,
you will have to pay the $44 application fee and
submit all required transcripts to be considered for
readmission.
Second Degree or
Certification Candidates:
Besuretolistadesiredmajororcertificationprogram
inthespaceprovided.
High School Students:
Ifyouwishtoapplyasaspecial,non-degreestudent
whilestillinhighschool,pleaseusetheUniversityof
WisconsinApplicationforUndergraduateAdmission.
Admissionrequirementsforhighschoolspecialstudents
arelistedintheUW-StoutUndergraduateBulletin.
3. Submitotherrequireddocumentationasdescribed
atright.
Additional Requirements:
Previous Degree Candidates must submit:
• Officialtranscriptsforallworkcompleted
atothercollegesoruniversitiessinceyou
lastattendedUW-Stout.
• A list of courses in progress if you are
currently enrolled at another college or
university.Includedepartment,coursenumber,coursetitle,andcreditvalueforeach
course.(A copy of your current student schedule
will suffice.)
If you were academically dropped:
Includealetterofappealindicatinganypossible
extenuating circumstances that led to your dismissal,and/orexplainwhyyoufeelyoushouldbe
readmitted.
Missing Documentation:
Upon examination of your application, UW-Stout
willletyouknowwhichitems,ifany,areneededto
completeyourapplication.
OFFICE OF ADMISSIONS
212 Millennium Hall, UW-Stout, Menomonie, WI 54751
Inspiring Innovation Learn more at admissions.uwstout.edu
5/11