Quincy University

Fall (August) 20 Spring (January) 20 Summer (June) 20

Full Time Part Time Resident On Campus Resident Off Campus

First Name Middle Initial Last Name
Male Female
Permanent Address:
City
Zip	County
Home Phone ( ) -	Cell Phone ( ) -
Date of Birth / /	Social Security Number - -
Are you a US Citizen? Yes No	Country of Citizenship
Resident Alien Identification No.	Country of Birth
International students, please list your TOEFL score:
If your primary language is not English, please list it here :
Can we reach you by e-mail? Yes No	E-mail Address
Religious Preference	Name of Parish, Synagogue or Church
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How would you describe yourself?	Native American Hispanic/Latin Asian Black/African American White Other
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What is your marital status?	Single Married Widowed Divorced
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Personal Conduct (Answer required. If you answer yes to either of these questions, you must submit a statement of explanation on a separate sheet of paper.)	a) Have you ever been expelled, suspended, or placed on probation by any secondary school or college you have attended, for reason of academic dishonesty or because of an offense that harmed or had the potential to harm others? Yes No b) Have you ever been convicted of a crimial offense other than a minor traffic violation, or been found to be delinquent by a juvenile court, or are there such charges currently pending against you at this time? Yes No