University of Wisconsin-Stout • Human Resource Management Certificate Application Form
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Student I.D. #____________________ Social Security Number*________________________________
E-mail address____________________________________________________________________________
Demographics
Last Name
First
Middle
Maiden (Prior)
Work Phone
Home Address
Street and No.
City
State/Zip
Home Phone
County
Birthdate: __________________________
Mo.
Day
Year
U.S. Veteran: o Yes o No
Gender:
o Male
o Female
* Use of your social security number is voluntary. It is used as the student ID number if one has not been assigned.
Resident History
Wisconsin resident? 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
Month/Year
Indicate the dates you have lived at your present address.
From: _________To: _________
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: _________
Parent’s name____________________________________________________________________________
Parent’s Address (last 2 years) ____________________________________________________________
From: _________To: _________
Have you, your spouse or parent(s) recently moved to Wisconsin to accept permanent full-time employment? o Yes o No
Do you claim legal Wisconsin residence for tuition purposes? o Yes o No
Marital Status:
o Single
o Married
Ethnic Background:
o American Indian or Alaskan Native
o Asian or Pacific Islander
o Cambodian, Laotian or Vietnamese
admitted to U.S. after 12/31/75
o Other Asian or Pacific Islander
o Black, non-Hispanic
o Hispanic/Latino
o White, non-Hispanic
Citizenship:
o Citizen
o Non-resident Alien
o Permanent Immigrant
Alien Registration Number
Country of Citizenship:_________________
Place of Birth:
Please Note: It is your responsibility to register correctly, as a resident or non-resident, under the law.
City
Semester you wish to begin: o Fall
o Spring
o Summer
Year 20_____
Certificate choice:_________________________________________________________
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.
Return form to:
Dr. Mitchell Sherman
University of Wisconsin-Stout
319 McCalmont Hall
Menomonie, WI 54751
Country
Education History
Signature Required
Signature
State
Date
E-mail: shermanm@uwstout.edu
Phone: 715.232.2658
Fax: 715.232.5303
List high school you graduated from and any institutions, colleges and universities attended:
Degree or diploma and
Name
Location
Dates
date awarded (Month/Year)
High School: __________________________________________________________________
College(s): __________________________________________________________________
__________________________________________________________________
Have you previously taken courses offered through UW-Stout, either on or off-campus?
o Yes o No
If yes, list date of last enrollment _____________________________
Do you plan to continue at UW-Stout?
o Yes o No
Intended major/program _____________________________o Undergraduate o Graduate
May 2010