Admissions bachelor of arts in general studies International Graduate Undergraduate Admissions Western Illinois University

Undergraduate Application for Readmission -
Office of the Registrar

Section I -- Personal Information
Last Name:
First Name:
Middle Name:
Previous Name:
Social Security Number: - -
Social Security Number is optional - for federal tax and state reporting purposes
WIU Identification Number:
(if applicable)
- -

Last Term Attended:
Date of Birth: ,
U.S. Citizen: If You are NOT a U.S. Citizen, provide the following:
Country: Visa Type: Alien Registration #:
Military Service: Have you served or are you serving on active duty with the armed forces? If yes, provide dates of service: to
National Guard or Reserve duty?

Ethnic Origin: Your response to the following will assist our efforts to ensure race/ethnic compliance reporting with federal agencies. This information will not affect admission.

1. Please indicate if you are Hispanic/Latino
Yes No

2. Please indicate your race (select one or more as appropriate)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
E-mail Address:
Permanent Address:
City:
State: If foreign address, provide country:
ZIP Code: -
County:
Phone: () -
Cell Phone: () -

If your Mailing Address is the same as your Permanent Address above, leave the following fields blank.
Otherwise, please provide complete Mailing Address information.

Mailing Address:
City:
State:
ZIP Code: -
County:
Phone: () -

Section II -- Application Information
Applying As: 
Degree-Seeking Student (not for B.A. General Studies program)
Degree Major:
*Major also available at WIU-Quad Cities campus
¹ Teacher education program available
² Teacher education program ONLY

Teacher education:

Nondegree-Seeking Student
Type
Applying For:
Location: Macomb campus
WIU-Quad Cities
Educational History:
List all colleges or universities attended or currently attending (including Western). If more space is needed, please use the comment box below.
College/University Name (including WIU) Dates of Attendance # Hours or Degree Earned



Section III -- Student Certification

This application must be signed and dated by the applicant before action can be taken. I understand that withholding information requested on this application or giving false information may make me ineligible for admission to the university or subject to dismissal. I certify that the information provided on the application is correct and complete. By signing this I also certify that I have read, and will adhere to all the components of the Criminal Record Disclosure Policy.

Criminal Record Disclosure:
Western Illinois University is committed to maintain a safe and positive environment for all members of the University community. Therefore, you are required to disclose information regarding your criminal or disciplinary background.

  1. Have you ever been convicted of, or been placed on court supervision for any criminal offense? (This does not include routine traffic offenses) Yes No
  2. Do you have any criminal charges pending against you? Yes No
  3. Have you ever been dismissed, or withdrew while charges were pending from any educational institution (including but not limited to high school or college) for any offense involving violence or the threat of violence? Yes No

If you answered "yes" to any of the questions above, please submit via certified mail a description of the incident(s), including name, date of incident(s), name of arresting agency(ies), as well as any additional relevant documentation. Additionally, please request the Circuit Clerk of the Court(s) in which the order of conviction(s) was entered to forward these record(s) to:

Western Illinois University, Sherman Hall Room 117, 1 University Circle, Macomb, IL 61455, attention to Campus Violence Prevention Enrollment Committee. These cases will be reviewed prior to an admission decision being made. Such disclosures do not automatically disqualify an applicant.


Comments:
If you have any questions or comments please let us know
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Verify the following:
By checking this box I certify that I am personally seeking readmission to Western Illinois University. I understand that withholding information requested on this application or giving false information may make me ineligible for admission to the University or subject to dismissal. I certify that the statements made on this application are correct and complete.


Please take time to review your information before completing your application.
Application information will be immediately submitted once button is clicked.


Board of Trustees International Graduate Student Services
Office of the Registrar | 1 University Circle | Sherman Hall 110 | Macomb, IL 61455-1390
Phone: (309)298-1891 | Fax: (309)298-2787 | E-mail: R-Office@wiu.edu
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