ࡱ> ?B> bjbjWW >(== <<$<f     $|.!j  555   5555 uF505!!5!5L"53'!< \: Reactivation Application (No application fee required, the application fee is a one-time only non-refundable fee.) TERM OF REACTIVATION: Fall 20______ Spring 20_______ Summer 20________ NAME Last (Print) First Initial Maiden Name SOCIAL SECURITY NUMBER: ____ ____ ____ - ____ ____ - ____ ____ ____ ____ UWW ID (if known) ___ ___ ___ ___ ___ ___ ___ PERMANENT ADDRESS Street City State Zip County MAILING ADDRESS (if different) Until / / Street City State Zip TELEPHONES: PERMANENT MAILING WORK ____ EMAIL ADDRESS: BIRTHDATE: ______________________ RESIDENCY: Do you claim legal WISCONSIN residence for tuition purposes? YES NO How long have you lived in Wisconsin? Years From / to / Years filed a Wisconsin income tax return? From / to / Month Year Month Year Month Year Month Year Current Place of Employment _________________________ From / to / Name City State Month Year Month Year Work Telephone Number - - Previous Place of Employment From / to / Name City State Month Year Month Year EDUCATION HISTORY: List in chronological order any education including all college or university, vocational-technical, extensional programs, etc. and any degree(s) earned (add additional sheet if necessary). Name of InstitutionCity/StateFrom Month/YearTo Month/YearDegree Received and Month/Year Graduate Program Name: (Ex: Counseling-School) I certify that this application is true and complete to the best of my knowledge and I understand that inaccurate information may affect my re-admission, enrollment, tuition, or financial status. I am aware that I will be officially admitted back into the program I started at an earlier date and I will not receive an additional notification of admission. Please mail the complete application to: School of Graduate Studies, 800 W Main St Whitewater, WI 53190 or email to gradschl@uww.edu. 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