UNIVERSITY OF ARKANSAS AT MONTICELLO

Admissions Application

Please note: Some fields will not accept punctuation, such as commas. All required fields must be completed. These are marked with a red (*) asterisk.

If yes, Which Degree?

Name:

*Last:

*First:

*Middle Initial:

Maiden Name:

Preferred Name:

*Social Security Number:

(ex. 999999999)

Mailing Address:

*Street/P.O. Box:

*City:

*County:

*State:

*Zip:

E-Mail:

Telephone:

(ex. 999-999-9999)

Work Number:

(ex. 999-999-9999)

Cell Number:

(ex. 999-999-9999)

If you have lived at the above address for less than six months,
provide previous address:

Street/P.O. Box:

City:

County:

State:

Zip:

*Date of Birth:

(mm/dd/yyyy)

*Place of Birth:

Are you or your parents currently on active duty in the military service?

*Name of Father, Mother, Legal Guardian, or Spouse:

*Relationship:

Street/P.O. Address:

City:

State:

Zip:

Telephone:

(ex. 999-999-9999)

I am applying as:

I am a :

Citizen of:

Visa Type:

Other

*Applying for:

Year: (ex. 07, 08, 09, 10)

Term:

I plan to:

For Statistical Purposes only (Voluntary Optional Information) :

Gender:

Do you consider yourself to be Hispanic/Latino? Yes No

Race/Ethnicity (select one or more):

At least one of my parents earned a college degree:

Academic Background

*High School:

*City and State:

*Graduation OR GED Date:

(ex. yyyy)

Have you ever attended UAM?

If yes, When?

Have you earned a degree from UAM?

List in chronological order, all the colleges and universities you have attended since high school, including UAM.

Institution/College	State/Country	Date(s) Attended(ex. 06-07)	Certificate Hours or Degree Earned

Are you currently enrolled at another college?

If yes, which one? yes, which one?

Do you plan to teach?

Are you currently teaching?

What grade level?

(K-12)

Seeking teacher Licensure?

If yes, what subject?

*Please indicate your planned field of study (select one only) or check: I have not decided

School of Agriculture

	Agriculture (B.S.)
	Specify:	Agriculture Business
		Animal Science
		General Agriculture
		Plant and Soil Science

School of Arts and Humanities

School of Business

	Accounting (B.B.A.)
	Business Administration (B.B.A.)
	Specify:	Business Administration
		Entrepreneurship
		Finance
		Management
		Marketing

School of Computer Information Systems

	Computer Information Systems (B.S.)
	Advanced Certification (B.A. / B.S. required)

School of Education
Undergraduate Program

	P-4 Early Childhood (B.A.)
	Middle Childhood Education 4-8 (B.A.)

P-12 Licensure Areas

	Music (B.A.)
	Specify:	Vocal
		Instrumental
		Piano
	Health and Physical Education (B.S.)

Non-Licensure Areas

	Health and Physical Education (B.A./B.S.)
	Health & Physical Education - Exercise Science (B.S.)

Graduate Programs

	Master of Arts in Teaching (M.A.T.) (Secondary content licensure areas, P-12 licensure in art, physical education, music, foreign language, middle childhood)
	Master of Education (M. Ed.)
	Master of Education Ed. Leadership

Non-Degree Option

Educational Leadership

School of Forest Resources

	Forestry (B.S.)
	Spatial Information Systems (B.S.)
	Wildlife Management (B.S.)
	Land Surveying Technology (A.S.)
	Master of Science (Forest Resources)

School of Mathematical and Natural Sciences

	Biology or Biology (B.S.)
	Chemistry (B.S.)
	Biochemistry
	Mathematics (B.S.)
	Natural Science (B.S.)

School of Nursing

	Nursing (B.S.N.)
	Nursing, RN (B.S.N.)
	Nursing, LPN to RN (A.A.S.N.)

School of Social and Behavioral Sciences

	Criminal Justice (B.S.)
	History (B.A.)
	History and Social Studies (B.A.)
	Political Science (B.A.)
	Psychology (B.S.)
	Social Work (B.S.W.)
	Crime Scene Investigation (A.A.S.)
	Law Enforcement Administration (A.A.S.)

Pre-Professional Studies
Allied Health

	Allied Health
	( Specify Field)
	Pre-Dentistry
	Pre-Engineering
	Pre-Law
	Pre-Medicine
	Pre-Pharmacy
	Pre-Veterinary Medicine

Division of General Studies

	Associate of Applied Science
	Specify:	Agriculture Production Mgmt
		General Technology
		Industrial Technology
	Associate of Arts
	Bachelor of Applied Science
	Bachelor of General Studies

	Other
	Specify:

Technical Certificates*

Certificates of Proficiency*

*Available through the Crossett and McGehee campuses only. ***Program requires prior completion of police academy curriculum.

(The University releases information on the quality of its teacher preparation program to the requirements of Section 207 of Title II of the Higher Education Act as amended in 1998. Official Title II data is published in appropriate University publications. Inquiries concerning Title II data should be directed to the Dean, School of Education, (870) 460-1062)
Proof of immunization against measles, rubella and mumps is required of applicants. Proof should be submitted as two MMR injections. Tuberculin skin testing required on foreign-born applicants.
Military Selective Service Act
Arkansas Act 228 of 1997 requires compliance with the Military Selective Service Act as a condition of enrollment in a public institution of higher education. No person who is required to register with the selective service system shall be eligible for admission to any public institution of higher education unless the person has signed a statement of selective service status.
*I swear under penalty of perjury that:
	I have registered with the selective service system in accordance with the Military Selective Service Act.
	I am not required to register with the selective service system because:
		I am under 18
		I am in the armed forces of the United States on active duty, other than in a reserve or national guard unit.
		I am an alien lawfully admitted to the United States as a non-immigrant under Section 101 (A)(15) of the Immigration and Nationality Act and am not required to register for as long as I maintain a lawful, non-immigrant status in the United States.
		I am a permanent resident of the trust territory of the Pacific Islands or the Northern Mariana Islands.
		I am female.
		I am excused from registration for another reason provided by federal law and that reason is:

*Failure to check below will make this application invalid. I certify that none of the information requested on this form is false or has been withheld. I understand that withholding information requested or giving false information may make me ineligible for admission and enrollment. I also understand that I will not be officially admitted until I have submitted credentials and met stipulated admission criteria. If I am a transfer student, I am verifying that I am admissible to the institution from which I am transferring.

I agree to these terms
I do not agree to these terms

STUDENTS WHO FALSIFY ADMISSION INFORMATION OR CREDENTIALS MAY BE DISMISSED FROM THE UNIVERSITY. The University of Arkansas at Monticello is firmly committed to complying with all applicable federal, state and local laws, and regulations, which provide educational and employment opportunities to all persons, regardless of their economic or social status. The University will not discriminate on the basis of race, color, religion, creed, gender, ethnic or national origin, disability, age, veteran status, or any legally protected class. The Office of Special Student Services has been designated to coordinate efforts to comply with all laws and regulations applicable to qualified disabled individuals, as required by Section 504 of the Rehabilitation Act of 1973. Inquiries concerning the applications of all federal laws and regulations regarding discrimination should be directed to Melodie Colwell, Babin Business Center, UAM, phone 870-460-1022.

Title IX Notice of Nondiscrimination can be viewed on the website at:
http://www.uamont.edu/pdf/Title%20IX%20Notice%20of%20Nondiscrimination.pdf

UAM's Annual Security and Fire Safety Report can be viewed on the website at: http://www.uamont.edu/StudentAffairs/PublicSafety/pdf/AnnualSecurityAndFireSafetyReport.pdf.

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