INFORMATION FORM
• Please print.
• Read the enclosed instructions carefully before completing this form.
• Be sure to sign the reverse side of this form. Attach additional pages if necessary.
• Please complete and submit this form with other application materials to the appropriate department.
1.
Check program for which you are applying:
□ HIM – Health Information Management
□ HN – Human Nutrition, Nutrition Science
2.
Check status for which you are applying: □ Undergraduate
3.
Are you currently enrolled at UIC? G Yes
□ HN – Human Nutrition,
Coordinated Program
□ Graduate*
*Project or thesis option in HN requires prior approval of Director of Accredited Nutrition Programs.
G No
If yes, please specify program(s) and term
If yes, please provide UIN
4.
Did you send your official transcripts to the Office of Admissions? □ Yes
□ No
5.
Are you presently applying for admission to any other program(s) at UIC? □ Yes
□ No
If yes, please specify program(s)
6.
7.
Last name
First
Middle
Former or Maiden
Social Security Number (optional)
8.
Permanent Legal Home Address: Number and Street or Rural Route
City or Town
County
Apt. No.
State (or Country)
Area Code and Phone Number
Zip Code
9.
Mailing Address: Number and Street or Rural Route
City or Town
10.
E-mail address
11.
Sex:
County
□ Male
□ Female
12.
Citizenship:
State (or Country)
Birthdate: Month – Day – Year
(use numbers)
14.
Apt. No.
-
13.
Area Code and Phone Number
Zip Code
Birthplace: City and State (or Country)
-
□ Citizen of U.S.A.
□ Immigrant or temporary resident
□ International: Country of Citizenship
, Country of Birth
□ Other
15.
Have you been a resident of Illinois for the previous six months? G Yes
16.
Your response to the following is voluntary and will not adversely affect your application. The information is requested so that this institution
may demonstrate its compliance with federal regulations. Failure to provide this information will not subject you to any adverse treatment.
(1) G Native American or Alaskan Native
(2) G Asian or Pacific Islander
(3) G Black or African American, not of Hispanic origin
(5) G White, not of Hispanic origin
(6) G Other
(specify)
G No
Hispanic origin categories:
(4M)G Mexican American
(4P) G Puerto Rican
(4C) G Cuban
(4Z) G Other Hispanic
(specify)
• Native American or Alaskan Native: Persons having origins in any of the original peoples of North America and maintaining cultural
identification through tribal affiliation or community recognition.
• Asian or Pacific Islander: Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or
the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.
• Black or African American, not of Hispanic origin: Persons having origins in any of the black racial groups of Africa.
• White, not of Hispanic origin: Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
• Hispanic: Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
17.
List ALL Colleges Attended (including current enrollment)
Name (in chronological order)
City
State (or Country)
From
Month
To
Year
Month
Year
Degrees Conferred
or
Hours Earned
1.
2.
3.
4.
5.
18.
Are you or have you ever been employed? G Yes
G No
From
To
Hours per week
A. Current Employer
B. Previous Employer
C. Previous Employer
D. Previous Employer
19.
In what extracurricular, volunteer, or community activities have you participated since graduation from high school (include offices held)?
20.
What honors have you received (include honorary societies)?
21.
Have there been any extenuating circumstances in your past experiences that have influenced your academic performance prior to your
application (e.g., financial difficulties, family responsibilities, illness, etc)? □ Yes □ No
If yes, please explain; include pertinent dates. (Use a separate sheet of paper; typing is preferred.)
22.
Are you bilingual? □ Yes
23.
Have you ever been enrolled in and/or dismissed from a health related professional program? □ Yes □ No
If yes, provide the name and location of all the programs and explain the circumstances under which you left or will leave (including UIC and
UIUC). Use a separate sheet of paper; typing is preferred.
24.
Have you ever applied to the UIC College of Applied Health Sciences (formerly College of Health and Human Development Sciences)?
□ Yes
□ No
□ No
If yes, which academic year(s)?
□ Health Information Management
□ Human Nutrition
25.
If yes, please specify language(s)
; which program(s)?
□ Medical Laboratory Sciences
□ Other
List the names of the 3 individuals providing your letters of recommendation, if applicable.
a) Recommendation #1
b) Recommendation #2
c) Recommendation #3
26.
I certify that the information submitted in this application is complete and correct to the best of my knowledge.
Sign legal name in full
Date
11/09