Application for Readmission
College of Arts and Sciences Pacific University
Submit Application to:
Via Postal Mail:
Office of the Associate Dean for Student Academic Affairs
Bates House, UC A143
Pacific University
Forest Grove, OR 97116
Via Fax: 503-352-2775
Via Email: smithsr@pacificu.edu
Student Information
(Please print or type information)
Name:__________________________________________________________________________________________
Last
First
Middle
Former Name (if applicable):________________________________________________________________________
Student ID: ______________________________
Date of Birth:____________________________
Social Security: XXX-XX - __ __ __ __
Phone Number:__________________________
Current Mailing Address:___________________________________________________
Number
Street
Apt#
___________________________________________________
City
Permanent Address:
State
Zip Code
___________________________________________________
(If different from current address)
Number
Street
Apt#
___________________________________________________
City
State
Zip Code
Email Address:___________________________________________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Date last attended Pacific University:_____________________________________________________
I wish to reenroll at Pacific (please circle a semester): Fall
Winter
Spring
Year:________________
Note: To be eligible to attend Winter term, a student must be a full time student during the following Spring Semester.
Anticipated completion date: Semester_______________ Year ________________
Have you attended another University or Academic Institution during your time away from Pacific? □ Yes
□ No
Name of Institution:_____________________________________ Term/Year of Attendance:_____________
Name of Institution:_____________________________________ Term/Year of Attendance:_____________
Do you plan to live in on-campus residence halls?:
□ Yes
□ No
Do you plan to apply for financial aid at Pacific University?: □ Yes
□ No
Have you filed a FAFSA?:
□ No
□ Yes
Former Pacific Faculty Academic Advisor:_________________________________________________
Anticipated Major: ____________________________________________________________________
Please check one:
____U.S. Citizen
____Permanent U.S. Resident
____Student visa or other visa
Ethnicity and Race:
In compliance with Federal regulation, the University must seek to identify the ethnic background of the students. You are urged to supply the
following information but may decline without in any way prejudicing your enrollment.
Do you consider yourself Hispanic or Latino/Latina? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin, regardless of race)
___Yes, Hispanic/Latino/Latina ___No, not Hispanic/Latino/Latina
In addition to your response to the prior question, please check one or more of the following groups of which you consider yourself a
member:
_______
American Indian (Original peoples of North, Central, and South America; maintaining Tribal Affiliation)
___ Alaska Native (A person having origins in any of the original peoples of Alaska, and who maintains tribal affiliation or community
attachment)
___ Asian (People of the Far East, Southeast Asia, or the Indian subcontinent)
___ Black or African American (Peoples having origins in any of the black racial groups of Africa)
___ Native Hawaiian (Peoples having origins in any of the original peoples of Hawaii)
___ Pacific Islander (Original peoples of Guam, Samoa, or other Pacific Islands)
___ White (Original peoples of Europe, the Middle East, or North Africa)
Please Read before signing Readmission Application

If you have attended a college or university since your departure from Pacific, you must arrange to have official transcripts of
the work sent to Pacific’s Registrar Office so that they may be evaluated.

Students who left Pacific due to academic suspension must first receive permission to apply for readmission from the Academic Standards Committee; please consult with the Associate Dean for Academic Affairs for more information on this process.

Applicants must be cleared by Pacific’s Business and Student Services Offices before readmission is allowed.

Only after clearances are received and the Registrar has been notified will you be able to register for classes.

You will be contacted via phone and email by the office of the Associate Dean for Student Academic Affairs once your application has been approved.

Should you need clarification or more information, consult the current college catalog or contact the Associate Dean for Student Academic Affairs Office for the College of Arts and Sciences (503-352-2201).
Applicant Signature:_________________________________________
Date:_____________________
A&S Office Use Only
Approval of Associate Dean: □ Yes
□ No
SACS:__________________________
Declared:
Signature:__________________________________
□ Vault:__________________
□ Yes □ No ___________________________
Readmission Clearance/Date
Unterseher (Student Services)_____________
Aust (Business Office) ___________________
Routing/Sent Date
Copy to Registrar ______________
Copy to Financial Aid __________
Vanzant (Business Office)________________
Emailed Student: □ Yes □ No _______________________
Housing Contract emailed: □ Yes □No
Called Student: □ Yes
Advising Appointment: _________________
□ No _______________________
Rev. 02/13/2012