University of Wisconsin-Stout • Stout Online
Registration Form
Please Print
Student I.D. #____________________________ Social Security Number*_______________________________________
E-mail address__________________________________________________________________________________________
Last Name
First
Middle
Maiden (Prior)
Work Phone
Home Address
Street and No.
City
County
State/Zip
Home Phone
Page 1
Demographics
Birthdate: _______________________________
Mo.
Day
Year
U.S. Citizen:
o Yes o No
U.S. Veteran: o Yes o No
Gender:
o Male
o Female
* If you have a UW-Stout student I.D. # you don't need to provide your Social Security #.
Continuing Students: If you are now enrolled or were registered through UW-Stout last semester stop here.
Turn registration form over and complete the other side of this form.
New and Re-entering Students: If you were not registered last semester, please complete both sides of registration form.
Marital Status:
o Single
o Married
Racial/Ethnic Heritage: You are not required to
disclose your racial/ethnic heritage. However,
your responses will help the UW System meet
federal reporting requirements.
Resident History
Wisconsin resident? o Yes o No
Ethnicity: Are you of Hispanic or Latino/a
origin? o Yes o No
If resident, how long have you lived in Wisconsin? Since ____ /____ (Month/Year)
When was the last year you filed Wisconsin income tax? 20___ (Year)
Month/Year
Indicate the dates you have lived at your present address:
Have you, your spouse or parent(s) recently moved to Wisconsin to accept
permanent, full-time employment? o Yes o No
Month/Year
From: _________ To:_________
Do you claim legal Wisconsin residency for tuition purposes? o Yes o No
List former addresses (street, city, state, country) within the last two years:
________________________________________________________________________________ ________________________________________________________________________________ From: _________ To:_________
From: _________ To:_________
Occupations and Activities During the Last Two Years
Occupation, activity, school or employer and address:
________________________________________________________________________________ ________________________________________________________________________________ From: _________ To:_________
From: _________ To:_________
If yes, choose one or more from the following list.
o Cuban
oPuerto Rican
o Mexican
oOther Hispanic
Mexican American or Latino/a
or Chicano
Race: Choose one or more from the list below.
o African American or Black
o American Indian or Alaska Native
o Native Hawaiian/Pacific Islander
o Cambodian
o Hmong
o Laotian
o Vietnamese
o Other Asian
o White
Graduate Credit Enrollees Only
Education History
o Yes o No I have applied for admission to the graduate college at UW-Stout
during the past five years.
List the high school you graduated from and any institutions, colleges and universities
attended:
Degree or diploma
o Yes o No I have previously enrolled in a graduate course through UW-Stout.
I have been admitted to the _________________________ graduate program.
o
I no longer want to pursue the above degree.
Name
and Location
Dates
date awarded (Month/Year)
High School: __________________________________________________________________
College(s): __________________________________________________________________
__________________________________________________________________
Note: Students seeking/changing a degree program must complete the Application for Graduate
Admission/Enrollment form, which is available from the Graduate College.
Have you previously taken courses offered through UW-Stout, either on or off-campus?
oPlease send me the application material to apply to a graduate degree program.
Do you plan to continue at UW-Stout? o Yes o No
oI plan to take courses as a non-degree special student for transfer or extend my
education. This does not constitute application/admission to a degree program.
Intended major/program _____________________________o Undergraduate o Graduate
o Yes o No If yes, list date of last enrollment: ___________________________
August 2013
Page22
Page
University of Wisconsin-Stout • Stout Online
Registration Form
Name_ ______________________________________________ Student I.D. #*_ _____________________________________
Year___________________________
Social Security #_____________________________________
Course Registration
Spring Semester
o Fall Semester
* If you have a UW-Stout student I.D. # you don't need to provide your
Social Security #.
Please register me in the following course(s):
Course ID
Sec.
U/G
Cr.*
Course Title
SAMP 701
800A
G
Introduction to Stout
Cr.
Meeting
Times
2 8:00 am - 4:00 pm o WinTerM
o Summer Session
Days
Begin
Date
End
Date
Location(s)
Sat.
6/14
8/14
Menomonie
* Type of credit: U=Undergraduate, G=Graduate
I plan to apply credit
toward:
o Bachelor’s degree at Stout
o Graduate degree at Stout
Signature Required
Fee Payment Agreement
Requirement
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 this university, I expect to be subject to its rules and regulations.
o Teacher certification
o Vocational certification
o Transfer to another college
Signature
Date
o Personal professional development
o Other, please state:
________________________
Note: Your registration is not complete until you have been admitted and this form is turned in to the appropriate office.
Return to:
Stout Online Registration
University of Wisconsin-Stout
All students must agree each term to
the Fee Payment Agreement located in
Access Stout underneath their individual account. Electronic consent must be
indicated before registering for courses
whether a student uses the fee payment agreement or not.
If you choose to use the Fee Payment
Agreement, you would need to make a
payment of 10% of total tuition at the
start of a term and then make successive payments within the term on due
dates provided by Student Business
Services.
Method
For additional information contact
Student Business Services at
715/232-1656.
109 Bowman Hall
Menomonie, WI 54751
Phone: 715/232-5167
or 715/232-2485
FAX: 715/232-2436
E-mail: outreachreg@uwstout.edu
www.uwstout.edu/de
August 2013