University of Wisconsin-Stout • Outreach Services
Please Print
Registration Form
Student I.D. #____________________ Social Security Number*________________________________
Email address____________________________________________________________________________
Demographics
Last Name
First
Middle
Maiden (Prior)
Work Phone
Home Address
Street and No.
City
State/Zip
Home Phone
County
Page 1
Birthdate: __________________________
Mo.
Day
Year
U.S. Veteran: o Yes o No
* Use of your social security number is voluntary. It is not required if you have a Datatel # assigned.
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.
Sex:
o Male
o Female
Marital Status:
o Single
o Married
Wisconsin resident? o Yes o No
Ethnic Background:
o American Indian or Alaskan Native
o Asian or Pacific Islander
o Cambodian, Laotian or Vietnamese
If resident, how long have you lived in Wisconsin? Since ____ /____ (Month/Year)
Resident History
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
Please Note: It is your responsibility to register correctly, as a resident or non-resident, under the law.
Graduate Credit Enrollees Only
o Yes o No I have applied for admission to the graduate college at UW-Stout during
the past five years.
o Yes o No I have previously enrolled in a graduate course through UW-Stout.
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:
City
State
Country
Education History
List high school you graduated from and any institutions, colleges and universities attended:
Degree or diploma and
Name
Location
Dates
date awarded (Month/Year)
oI no longer want to pursue the above degree.
High School: __________________________________________________________________
College(s): __________________________________________________________________
__________________________________________________________________
Note: Students seeking/changing a degree program must complete the Application for Graduate
Have you previously taken courses offered through UW-Stout, either on or off-campus?
I have been admitted to the _________________________ graduate program at UW-Stout.
Admission/Enrollment form, which is available from the Graduate College.
o Yes o No
If yes, list date of last enrollment _____________________________
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 simply to extend my education. This does not constitute application/admission to a degree program.
Intended major/program _____________________________o Undergraduate o Graduate
April 2008
8University of Wisconsin-Stout • Outreach Services
Registration Form
Name ________________________________________________ Social Security Number*_______________________________
* Use of your social security number is voluntary. It is not required if you
have a Datatel # assigned.
Course Registration
Student I.D. #_________________________________________
Please register me in the following course(s):
Course ID
Sec.
SAMP 701
600A
U/G
Course Title
Cr.
Cr.*
G
Introduction to Stout
Meeting
Days
Times
2 8:00 am - 4:00 pm Sat.
Page
Page
2 2
Year___________________________
Please check one:
o Spring Semester
o Fall Semester
o WinTerM
o Summer Session
Begin
Date
End
Date
Locations
9/4
12/14
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
o Teacher Certification
o Vocational Certification
o Transfer to Another College
o Personal Professional Development
o Other, please state:
________________________
PAYMENT PLAN AGREEMENT REQUIREMENT
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
this university, I expect to be subject to its rules and regulations.
Signature
Date
Note: Your registration is not complete until you have been admitted and this form is turned in to the appropriate office with the signed Payment
Plan Agreement Form.
Credit Outreach Students:
Outreach Registration
University of Wisconsin-Stout
109 Bowman Hall
Menomonie, WI 54751
Phone: 715/232-5167 or 715/232-2485
FAX: 715/232-2436
www.uwstout.edu/outreach/ces/
Method of Payment (please check one)
o Mastercard
o Check (payable to UW-Stout)
o Visa
o Purchase order (must accompany registration)
Card Number **__________________________________________________________________
Expiration Date___________________________________________________________________
Total amount enclosed or charged: $_ ______________________________________________
**
All students must complete the University of
Wisconsin payment plan agreement/application found at:
www.uwstout.edu/stubus/PDF/ppagree.pdf.
Minnesota residents should refer to payment plan for details on reciprocity.
Students who opt for the payment plan
must make their first $200 payment at
the end of the first week of classes. These
dates are defined by the campus regular
semesters and not the start date of individual courses. No payment plan is available
for Summer Session or WinTerM. This form
can be mailed to the address to the left or
faxed to (715) 232-1390. For more information on the payment plan option, contact:
UW-Stout Student Business Office
(715) 232-1656
This information gives UW-Stout authorization to charge the registration fee to the above card.
April 2008