Fillable Printable Non-Degree Student Application and Registration Form - Wright State University
Fillable Printable Non-Degree Student Application and Registration Form - Wright State University
Non-Degree Student Application and Registration Form - Wright State University
Non-Degree Student
Application and Registration Form
Undergraduate & Special Grad
Raider Connect
3640 Colonel Glenn Hwy.
Dayton, OH 45435-0001
(937) 775-4000
FAX: (937) 775-5597
RaiderConnect@wright.edu
A $10 application fee will be assessed with other fees.
Return to RaiderConnect
For academic advising,
call the University College, (937) 775-5750.
University ID (UID) (if known)
—
—
Indicate semester you wish to register
You must be a degree student to qualify for federal
student financial aid programs
Social Security Number
☐
Fall
☐
Spring
☐
Summer
Last name
First name
Middle name
Maiden name
County: check or enter Ohio county
Street address
☐
Montgomery
☐
Greene
☐
Clark
☐
Miami
City
State/Zip
☐
Mercer
☐
_______________________
( )
( )
Home phone
Business phone
Email Address
☐Male ☐ Female
Month/Day/year of birth
(This information is required by the federal government; however, reporting it on this form is strictly voluntary.)
Ethnicity: (choose one)
☐Hispanic/Latino ☐Non-Hispanic/Non-Latino
R
ace: (choose one or more)
☐American Indian/Alaskan
Native
☐Asian
☐Black/African
American
☐Native Hawaiian/Other
Pacific Islander
☐White
Educational Information:
Have you ever attended Wright State University?
☐
Yes
☐
No
High school attended
City/State
Year of graduation
Last college attended/College awarding degree
City/State
Degree awarded and year earned
☐
Yes
☐
No
Was cumulative grade point average above 2.0 on a 4.0 point scale at your last college attended?
If not, you must contact the Office of Admissions, E148 Student Union, (937) 775-5700, before you register.
Resident/Nonresident Information
U.S. citizen?
☐
Yes
☐
No
If not a citizen, what visa? _______________
For the purpose of determining fees, students are classified as Ohio or non-
Ohio residents. If you are a U.S. citizen or are here on an immigrant visa
and you can reply yes to any of the statement below, you will be considered
a resident.
Please indicate with an (x) if you do not want
☐ to be billed for student insurance
Have you ever been convicted of a felony?
☐
Yes
☐
No Date of Conviction: ____/____/__________
☐
No I do not reside in Ohio (nonresident)
Have you ever been dismissed for disciplinary reasons from an academic
institution?
☐
Yes I reside and am gainfully employed on a self-sustaining basis in Ohio
and wish to pursue a part-time program.
☐
Yes
☐
No Date of dismissal: ____/____/__________
☐
Yes I am on active duty in the United States military service and am
stationed and residing in Ohio, or I am a dependent of such a person.
Enter Preferred Classes
Line
no.
Dept.
Course
number
Section
number
Credit
hours
1
2
3
4
5
☐
Yes I have lived in Ohio for at least twelve consecutive months prior to
this enrollment and am not receiving financial support from non-Ohio
residents.
☐
Yes I am a dependent student with at least one parent or guardian
residing in Ohio for at least twelve consecutive months prior to this
enrollment.
Please select alternate classes should your preferred classes be closed.
Registration Agreement and Promise to Pay
By signing this agreement with Wright State University, I am requesting to
be registered for classes and promise to assume financial responsibility for
the payment of all my education-related charges and fees associated with
my student account and to pay those charges when due. In the event my
account becomes past due, I acknowledge that a registration and transcript
hold will be placed on my account and my account may be reported to the
credit bureau and referred to the State of Ohio Attorney General’s Office
for collection. I agree to pay all late fees, collection costs, and attorney fees
related to the collection of my account.
Enter Alternate Classes
Alt.
for
Line
no.
Enter alternate classes with corresponding line
number for preferred classes
Dept.
Course
number
Section
number
Credit
hours
Repeat-R*
Audit-A*
Ohio law requires that non-resident fees be assessed to male Ohio students who are between
the ages of 18 and 25 and have not registered with Selective Service.
Updated 03/23/2015
Signature
Date
