Application for Certification Program Enrollment
Consult the accompanying instructions. Attach all materials requested.
Submit to the School of Education, UW-Stout, 267 HERH, Menomonie, WI 54751
Date of Birth (mo/day/yr)
Gender: ❏ Male ❏ Female
Personal Information
U.S. Veteran: ❏ Yes ❏ No
Stout ID Number
Social Security Number*
Last Name
First
Permanent Home Address
Mailing Address
Middle
Maiden (Prior)
Street and No.
City
Country
Street and No. (No P.O. box) City
Current E-Mail Address
Racial/Ethnic Heritage:
❏ African American or Black
❏ American Indian or Alaskan Native
❏ Hawaiian or Pacific Islander
❏ Cambodian
❏ Hmong
❏ Laotian
❏ Vietnamese
❏ Other Asian
❏ Cuban
❏ Mexican, Mexican American, or Chicano/a
❏ Puerto Rican
❏ Other Hispanic, or Latino/a
❏ White or Caucasian
❏ Other (specify)
❏ I do not wish to provide this information
Permanent Phone
Country
State/Zip
State/Zip
Home Phone
Cell Phone
Citizenship:
❏ United States Citizen
❏ Permanent Resident (immigrant)
Registration Number:
❏ Non-Immigrant Alien Country: _______________
* Use of SS# is optional if you have a UW-Stout ID number
Enrollment Information Anticipated first enrollment (enter year)
Semester 1-August 20 ____
Semester 2-January 20 ____
WinTerm (3wks) 20 ____
Summer Session 20 ____
WI DPI Certification Options through UW-Stout School of Education
Please check the certification and level (graduate(GR) / undergraduate(UG)) for which you are applying
GR UG
☐ Art (550)
☐ ☐ Biology (605)
☐ ☐ Broadfield Science (601)
☐ ☐ Business Ed (250/281)
☐ ☐ Chemistry (610)
☐
CTE Coord (formally LVEC) (93)
GR UG
☐ ☐ Early Childhood (777)
☐ ☐ Early Middle Childhood (777)
☐ ☐ Early Childhood Special Ed (809)
☐ Economics (710)
☐ Family & Consumer Ed (210)
☐ ☐ Health (910)
☐ History (725)
GR UG
☐ ☐ Marketing Ed (285)
☐ Math (400)
☐ ☐ Physics (625)
☐ ☐ Special Ed Cross Cat (801)
☐ ☐ Special Ed Cog Dis (810)
☐ ☐ Technology Ed (220)
Distance Delivery
GR UG
☐ ☐ Business Ed (250/281)
☐ ☐ Fam Consumer Ed (210)
☐ ☐ Marketing Ed (285)
☐ ☐ Technology Ed (220)
Residency
The following data is needed to determine if you should be charged in-state or out-of-state tuition. Criteria for determining residence status for tuition
purposes 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.
Wisconsin resident? ❏ Yes ❏ No (list state of residence)
If resident, how long have you lived in Wisconsin? Since /
(Month/Year)
Last year you filed Wisconsin income tax? 20
(Year)
Indicate the dates you have lived at your present address. From:
/
List former addresses (street, city, state, country) within the last two years:
(Month/Year) to
/
(Month/Year)
From:
From:
To:
To:
Last Voter Registration (city, state, mo/yr) ______________________
Occupation, activity, school or employer and address
From:
From:
Parent’s name
Parents address (last 2 years)
From:
To:
To:
To:
Have you, or your spouse or parent(s) recently moved to Wisconsin to accept permanent full-time employment? ❏ Yes ❏ No
Education History
The following information is needed to determine which educational documents, if any, will be needed to complete your application. List in chronological
order all education beyond high school including any college, university, vocational-technical school extension, or service schools and any degree(s) earned.
Name
Location
Dates
Degree or diploma (mo/yr awarded)
High School:
Colleges:
Application must be signed and dated to be processed. I certify that I am applying to a specific certification, that the information in this application is true
and complete to the best of my knowledge, and that I understand that inaccurate information may affect my enrollment.
Signature:
Revised: May 05, 2015
Date: