Application Form
Please fill out all applicable information:
(Required fields marked with an *)

Classification: New Freshman Transfer Student Re-admit student
*Email :
*Last Name :
*First Name:
Middle Name
*Date Of Birth: Month: Day: Year:
*Sex: Male Female
  Permanent Address
   
*Street: *City:
*State:    
Home phone number:
 Work phone number:
Address to which admissions information should be sent, if different than above: (notify promptly if changed)
Street: City:
State: Zip: -
phone number:
-
College Plans:
What will be your proposed major(s) or field(s) of study?
1st choice:
2nd choice:
What is your educational
goal at this institution?		 Bachelor's degree
Associate degree
Transfer
Last high school attended:
Name
City
State
Zip
Dates of attendance: month yr
month yr
Date of Graduation: month yr
If you are applying as a freshman, you must send official high school transcripts.
If not a high school graduate, have you earned a GED certificate? Yes
No
Date: month yr
State or agency:
You must submit a copy of your high school
equivalency certificate and GED test scores.
College Education:
Have you attended, or are you currently attending another college?

Yes
No
If Yes, completion of questions in this section is required.
Name of College/University:
 State:
Dates of attendance:
month yr to
month yr
Degree earned:
Date:
Name of College/University:
 State:
Dates of attendance:
month yr to
month yr
Degree earned:
Date:
*First Name:
*Last Name:
*Todays Date: mo. day: yr.
 
If you feel that any of the information you may have entered is
incorrect, or you'd like to start over, click the button below.

For more information or to request application materials by mail, e-mail us: icuaadmin@icua.com

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