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

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