APPLICATION FOR ADMISSION FOR NONDEGREE GRADUATE STUDY

Graduate Studies Office University Administration Building Room 121 University at Albany Albany, New York 12222 (518) 442-3980 e-mail: graduate@uamail.albany.edu web: http://www.albany.edu/

Please complete this form according to the instructions for nondegree graduate applications. PERSONAL INFORMATION
Mr. Ms. Name:	Last (Family)	First (Given)	MI	Other
U.S. Social Security Number:      Birth Date: Month:  Day:  Year:
Permanent Mailing Address:
Street:
City:      State:    Zip:
Telephone Number:        Business Number:        Email Address:
I voluntarily seek to identify myself as disabled and request information regarding available University services to support disabled individuals:   Yes   No

FOR U.S. CITIZENS/PERMANENT RESIDENTS: Are you a New York State resident? Yes   For how long?  Years   Months  Please indicate NY county of residence:  No    Please indicate state of residence:  Student Ethnic Data:   (Optional. The following information is requested for statistical reporting purposes only, and will not be used as a selection criterion for admission.)    White, non-Hispanic (Not of Hispanic Origin)    Black, non-Hispanic (Not of Hispanic Origin)     Hispanic/Latino    Asian / Pacific Islander   American Indian / Native Alaskan    Other  For International Applicants only, please provide the following information:    Country of Citizenship:    City and Country of Birth:    Current Visa Status:

PROGRAM INFORMATION Have you ever studied at the University at Albany as a graduate student?     Yes    No Semester and Year you wish to enter:    Fall    Spring    Summer     Year:       Please list your specific intended course(s), if known, and your proposed area/field of study Accounting Africana Studies Anthropology Art Studio Atmospheric Science Biology Biomedical Sciences Biometry and Statistics Business Administration Chemistry Classics Communication Computer Science Counseling Psychology Economics Education - unspecified Educational Administration Educational Psychology English Environmental Health and Toxicology Epidemiology French Geography Health Policy & Management History Humanities Informatics Information Studies Latin American and Caribbean Studies Liberal Studies Literacy Mathematics NanoScale Science and Engineering Organizational Studies Philosophy Physics Political Science Psychology Public Administration Public Affairs/Policy Public Health Reading Russian School Psychology Social Studies Social Welfare Sociology Spanish Special Education Taxation Teacher Education Theatre Urban & Regional Planning Women's Studies

ACADEMIC INFORMATION

Identify the institution which will have granted your highest degree prior to admission:  University at Albany     Other  (Please Specify):

Have you ever been convicted of a felony?    Yes     No

Have you been dismissed from a college for disciplinary reasons?    Yes     No

I certify that the information provided in this application is true and complete to the best of my knowledge. I am aware that if the information provided in this application proves to be inaccurate, I may not be admitted for graduate study and/or my registration will be terminated.  Yes Date:

University at Albany, State University of New York does not discriminate on the basis of age, color, creed, disability, marital status, national origin, race, or sex. Inquiries concerning the policy should be directed to the Office of Diversity and Affirmative Action.