Adult & Part-Time Application For Undergraduate Admission Form
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1
2Fairleigh Dickinson University
ADULT & PART-TIME APPLICATION for UNDERGRADUATE ADMISSION
Complete this application if you are a U.S. citizen or permanent resident of the U.S. planning to enroll in day, evening, weekend or online
classes on a part-time basis, or if you are 25 years of age or older. International students can call 201-692-2205 to request an application.
Please type or print.
I. GENERAL INFORMATION
Last Name __________________________________________________ First ______________________________ Middle Initial__________
Maiden Name __________________________________________________________________________________________________________
Permanent Address ____________________________________________________________________________________________________
City ________________________________________________________ County __________________________________________________
State/Province ______________________________________________ Zip ______________________________________________________
Home Phone (_______) ______________________________________ Business Phone (_______) __________________________________
Cell Phone (_______) ________________________________________ Email ____________________________________________________
bbb bb bbbb
Social Security No.
Date of Birth ______________________________________________
Month
Day
Year
b
b
Gender:
Male
Female
A. Optional Information
(for statistical purposes only)
b
b
1. Are you Hispanic/Latino?
Yes
No
b
b
b
2. Please check:
American Indian or Alaska Native
Asian
Black or African American
b
b
Native Hawaiian or Other Pacific Islander
White
(optional)
B. Employment Information
Employer ________________________________________________ Position __________________________________________________
Business Address ____________________________________________________________________________________________________
City ______________________________________________________ State __________________________ Zip ______________________
b
b
Will you receive tuition reimbursement from your employer?
Yes
No
C. Citizenship Information
b
b
Are you a U.S. citizen?
Yes
No
b
b
Are you a permanent resident?
Yes
No If yes, please provide your:
Alien Registration Number _________________________________ Country of Citizenship_____________________________________
D. Veteran Status
b
b
Are you a member of the U.S. armed forces?
Yes
No If yes, please complete the following:
b
b
b
Current military status:
Active Duty
Reserves
Veteran (prior service)
b
b
b
b
b
b
Branch of service:
Air Force
Army
Coast Guard
Marine Corps
Navy
National Guard
E. Other Information
b
b
Have you ever been convicted of a felony?
Yes (Please explain using a separate sheet of paper.)
No
Have you ever been suspended, expelled or required to withdraw from any secondary or post-secondary institution?
b
b
Yes (Please explain using a separate sheet of paper.)
No
II. ENROLLMENT INFORMATION
(If you are unsure of your enrollment status or choice of degree program, call the Office of Undergraduate
Adult & Part-Time Admissions at 201-692-2551.)
I am applying as:
b
b
b
First-time Student
Transfer Student
Readmitted Student (Application fee is waived.)___________________________________
Dates of Attendance
I plan to enter FDU:
b
b
b
b
b
b
Fall 20_____
Spring 20_____
Summer I 20_____
Summer II 20_____
Summer III 20_____
Winter Session 20_____
My preferred campus is:
b
b
b
Metropolitan Campus (Teaneck, NJ)
College at Florham (Madison, NJ)
Off-Campus Site _______________________________
I will enroll as:
b
b
b
b
b
Degree-Seeking Student
Non-Degree Student
For Credit Classes
Visiting Student
Auditor (Non-credit)
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