Undergraduate Nondegree Student - Credit Enrollment Data Form

Students registering for the first time at Penn State as a nondegree undergraduate student must complete and return this form to the Registrar's office at the campus where enrollment is planned.

Semester/Session             Sex
 Spring    20___           Male                    Wilkes-Barre                    ______________________
 Fall          20___          Female              Campus Location                       Date of Birth
 Summer  20___

Ethnic Background (Check one)	Highest Level of Education (Check one)
a. American Indian	Non High School Graduate
b. Alaskan Native	High School Graduate
c. Black/African-American (not of Hispanic origin)	1-59 College Credits Completed
d. Asian-American or Pacific Islander	60 or more College Credits Completed
e. Hispanic-American (not Puerto Rican)	Bachelor's Degree
f. Puerto Rican
g. White American (not of Hispanic origin)
h. Other (in U.S. on Student or Temporary Visa)

Home Address                                                                               Local Address
____________________________________________                __________________________________________________
Number                   Street                             County                                                Number                           Street
____________________________________________                __________________________________________________
Apartment                                                    Country                                                Apartment
____________________________________________                __________________________________________________
City                             State                         Zip                                                        City                                State                                                       Zip
(______)_____________________________________               (______)___________________________________________
Home Telephone                                                                                                        Local Telephone

REGISTRAR: Please send a copy of this form to the Fee Assessor, 103 Shields Building, If (1) an out-of-state home address is listed or
                          (2) an "h - Other" ethnic code is marked.

1. Are you a U.S. Citizen?    Yes    No       If no, which one of the following statements accurately describes your citizenship status?
          I am an immigrant (permanent resident) residing in Pennsylvania.
          I am an immigrant (permanent resident) residing in another U.S. state or territory.
          I have a nonimmigrant visa.      Specific type:_______________________________________________
2. Are you a legal resident of the State of Pennsylvania?   Yes    No    If yes, more than one year? ______less than one year? ______
3. If you are under age twenty-one, indicate who of the following is a legal resident of the State of Pennsylvania:
         Parent?       Yes   No
         Spouse?      Yes   No
         Guardian?    Yes   No

Note: If you answered yes to question two or any part of question three, but show an out-of-state permanent address in home address,
          supply documentary evidence of legal residency in the State of Pennsylvania to the Fee Assessor's office, 103 Shields Building.

4. Have you ever been enrolled at Penn State?   Yes      No       Year and Semester:___________________________
5. Are you currently in academic drop status from Penn State or any other college or university previously attended?        Yes    No
6. Are you currently dismissed or suspended from Penn State or any other college or university for disciplinary reasons?    Yes    No

High School Attended: If graduated, give date.                                                    List Previous Colleges Attended: If graduated, give date.
_______________________________________           ________________________________________
_______________________________________           ________________________________________
_______________________________________           ________________________________________
City                                  State

I have completed all applicable spaces on this form and I affirm their accuracy. Should there be any misrepresentation of facts on this form, I
understand this may be cause of refusal or cancellation of my enrollment.

________________________________________________________________________________________________________________________________________
Signature                                                                                                                                                                                   Date
                                     REG 0200 REV 04/93