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UFTL Student Disclosure Form

* = Required Fields
  Date of Birth
 
Last Name *   Country of Citizenship
 
Mailing Address   Native Language
 
City    
   
State   Place of Birth
 
Zip Code   Social Security #
     
Are you a UFTL employee?   Gender Type
Yes No   Male Female
Are you a dependent UFTL employee?   Phone Number *
Yes No  
Email Address   Work Number *
 
     
Please specify if other:
/// PREVIOUS EDUCATION
Name of High School *   Date Recieved MM/DD/YY*
  Diploma Received? Yes No
Mailing Address   If you have taken, or plan to take any of the following tests, indicate Date
  GRE (Graduate Record Exam)
City   Date MM/DD/YY*
  GMAT (Graduate Admissions Test)
State    
  Date MM/DD/YY*
Zip Code   LSAT (Law School Admissions Test)
    Date MM/DD/YY*
    Other (please specify)
    Date MM/DD/YY*
     
Planned semester of enrollment:   Do you expect to register as a full-time student?
Fall Spring Summer   Yes No
    Please specify your program of study:
   
     
List ALL colleges and universities (last listed first) regardless of length of attendance or work completed.
  Name of Institution Date Attended From
 
  City Date Attended To 
 
  Semester Hours Completed/Currently Enrolled
State Zip Code
Degree Received  
     
  Name of Institution Date Attended From
 
  City Date Attended To 
 
  Semester Hours Completed/Currently Enrolled
State Zip Code
Degree Received  
       
Have you previously registered for course work at University of Fort Lauderdale? If yes, please specify exact date of attendance:
Yes No   Date Attended From
    Date Attended To    
Please list any relatives who are UFTL students or alumni.
  First Name
  Last Name
Church Affiliation   Address
 
Pastor’s Name   City
 
    State
   
    Zip Code
Do you have any physical disabilities?
Yes No
If yes, please explain>>>

 

     
/// ACCEPTANCE AND SIGNATURE
By my signature, I agree to the conditions of this contract. I also agree that it is my responsibility to print a copy of this application for my records, complete an Enrollment Agreement and it is my responsibility to obtain a copy of the school's catalog.

I certify that all information supplied by me in this application is correct and complete. I understand that any misrepresentation or falsification, including failure to report any college or university attendance, is sufficient cause for cancellation of enrollment and/or any credits earned from University of Fort Lauderdale.

Full Name *

Date MM/DD/YY*
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