Readmit Application Form

Required Information

First (Given) Name *

Middle Name

Last (Family) Name *

Preferred Name, if not first name

Mailing Address *

Country

Street

City

Region

Postal Code

Sex (as reported on your birth certificate) *

Additional information regarding your gender identity

Are You Hispanic or Latino?

Race

Date of Birth *

Social Security Number

Mobile Phone *

Email *

First Term at Ursinus

Starting Academic Year at Ursinus

Last Term at Ursinus

Last Academic Year at Ursinus

Reason for leaving Ursinus

Primary Academic Interest

Which entry term are you planning on returning?

Have you attended any other institutions since leaving Ursinus?

If yes, please complete the following section. List in chronological order, most recent first, ALL colleges and universities you have attended. If you have attended more than two schools, please provide the required information in an email to admission@ursinus.edu. (Example: Name of College University/Fall 2016-Spring 2017)

Has disciplinary action been taken against you at any of the institutions you attended?

If yes, please explain:

Have you ever been convicted of a felony offense?

A conviction is an adjudication of guilt and includes pleas of nolo contendre (no contest). Please disregard minor traffic violations, offenses committed before your 18th birthday which were adjudicated in juvenile court under a Youth Offender Law, and any charges which have been expunged by a court or for which you successfully completed an Accelerated Rehabilitative Disposition Program. A “yes” answer will be reported to the Pennsylvania Higher Education Assistance Authority (PHEAA) if the applicant receives PHEAA aid. A “yes” answer will not necessarily bar readmission to the College, but it may limit the ability to enroll in or complete certain academic majors/programs and may affect approval to live in college-owned or college-affiliated housing, should that be requested. If yes, please state the felony offense, date of conviction and provide relevant information concerning the felony conviction:

I certify that I have answered all applicable questions and that all information is true to the best of my knowledge. I understand that any deliberate falsification or omission of application data may result in denial of readmission or dismissal. Full Name/Date