Western Illinois University

* Last Name:

* First Name:

Middle Name:

Previous Name:

Social Security #:

SSN is optional - required for federal tax and state reporting purposes

WIU ID #:

* National Guard or Reserve duty?

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

Please indicate if you are Hispanic/Latino:

Please indicate your race: (Select one or more as appropriate)

* Permanent Address:

Apartment/Suite:

* City:

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* Postal (Zip) Code:

* County: Adams Alexander Bond Boone Brown Bureau Calhoun Carroll Cass Champaign Christian Clark Clark MO Clay Clinton Clinton IA Coles Cook Crawford Cumberland DeKalb DesMoines IA DeWitt Douglas DuPage Edgar Edwards Effingham Fayette Ford Franklin Fulton Gallatin Greene Grundy Hamilton Hancock Hardin Henderson Henry Iroquois Jackson Jasper Jefferson Jefferson MO Jersey Jo Daviess Johnson Kane Kankakee Kendall Knox Lake Lake IN LaSalle Lawrence Lee Lee IA Lewis MO Livingston Logan Louisa IA Macon Macoupin Madison Marion Marion MO Marshall Mason Massac McDonough McHenry McLean Menard Mercer Monroe Montgomery Morgan Moultrie Muscatine IA Not in This List Ogle Peoria Perry Piatt Pike Pope Porter IN Pulaski Putnam Randolph Richland Rock Island Saline Sangamon Schuyler Scott IA Scott IL Shelby St Charles MO St Louis City MO St Louis Mo St. Clair Stark Stephenson Tazewell Union Vermilion Wabash Warren Washington Wayne White Whiteside Will Williamson Winnebago Woodford Not in Illinois

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* Email Address:

Important information will be sent to this address. Ensure that it is valid.

* At least one phone number is required.

Home Phone:

Cell Phone:

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

Mailing/Current Address:

Apartment/Suite:

City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Northern Mariana Islands Puerto Rico United States Minor Outlying Islands Virgin Islands Outside Of USA

Postal (Zip) Code:

Phone:

Emergency Contact Details

* Last Name:

* First Name:

Address:

Apartment/Suite/Other:

City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Guam Northern Mariana Islands Puerto Rico United States Minor Outlying Islands Virgin Islands Outside Of USA

Zip:

Email Address:

At least one emergency number is required.

* Daytime Phone:

* Evening Phone:

Relationship to You: Parent Guardian Spouse Other

If other:

* Returning As:

Public Act 102-0214 requires that the Board of Trustees of each public university in the state, upon a student declaring or changing their academic major or program of study, provide the student with an Occupational Outlook Report associated with that major.

Degree Major:

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Type:

Reentry Term:

* Semester: Fall (August) Spring (January) Summer (July)

* Year: 2025 2026

* Location:

* Educational History:

Comments:

This form must be signed and dated by the applicant before action can be taken. I understand that withholding information requested on this form or giving false information may make me ineligible for reentry to the university or subject to dismissal. I certify that the information provided on this form 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 maintaining 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.

A) Have you ever been convicted of, or been placed on court supervision for any criminal offense? (This does not include routine traffic offenses)

B) Do you have any criminal charges pending against you?

C) Have you ever been dismissed, or withdrawn 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?

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), location 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 a reentry decision being made. Such disclosures do not automatically disqualify an applicant.

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