Form UWSQ Submitted

Form UWSQ submitted by 60637373 on 2015-05-20 10:50:18 AM Pacific

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Application for Summer-Only Admission

Application fee: $60.00, Page 1 of 3

IMPORTANT: After June 1, please use the Summer-only Application Form and do not apply online. High school students may not apply online at any time and must use the Summer-only Application Form.

For further information please go to the UW Summer Quarter Website.

Academic History

1. Have you ever attended UW credit classes before Summer Quarter 2015?
[ ] Yes [X] No

If Yes:

UW Student Number (if able to recall):

[---]

Last quarter/year you were enrolled:

[---]

If No:

Have you earned a bachelor's degree at another college?

[X] Yes [ ] No

2. What is the last school you will have attended before summer quarter 2015?

High School:

Find	CEEB Code	Name of High School	Location City,	State,	Country (if other than U.S.)
	[9999]	[Queen of Angels]	[San Fernando]	[CA]	[---]

College:

Find	CEEB Code	Name of College	Location City,	State,	Country (if other than U.S.)
	[9999]	[University of California]	[Irvine]	[CA]	[---]

Page 1 of 3

Application for Summer-Only Admission

Application fee: $60.00, Page 2 of 3

Campus Selection

3. I wish to attend classes at

[ ] Bothell [X] Seattle [ ] Tacoma

Term:

[Summer Quarter 2015 (UWSQ15) ]

Personal Data

4. Social Security Number

[000-00-0000](xxx-xx-xxxx)

5. Gender

[X] Male [ ] Female

6. Date of Birth

[06-21-1948](mm/dd/yyyy)

7. Legal Name

First Name
[Paul]

Middle Name
[Andrew]

Last Name
[Mitchell]

8. Other Names: If your name has changed, indicate your former full name(s) or other variations of your name

Last
[---]

First
[---]

Middle
[---]

Last
[---]

First
[---]

Middle
[---]

Address Information

9. Mailing address

Country:

[United States (US) ]

Street Address:	[117 East Louisa Street]
Street Address Line 2:	[c/o Lake Union Mail]
City:	[Seattle]
State:	[Washington (WA) ]
Zip Code:	[98102] - [3203]

Street Address:	[---]
Street Address Line 2:	[---]
City:	[---]
Province:	[---]
Postal code	[---]

Street Address:	[---]
Street Address Line 2:	[---]
City:	[---]
Province/Territory and Postal Code Information:	[---]

10. Permanent Address

Country:

[United States (US) ]

Street Address:	[117 East Louisa Street]
Street Address Line 2:	[c/o Lake Union Mail]
City:	[Seattle]
State:	[Washington (WA) ]
Zip Code:	[98102] - [3203]

Street Address:	[---]
Street Address Line 2:	[---]
City:	[---]
Province:	[---]
Postal code	[---]

Street Address:	[---]
Street Address Line 2:	[---]
City:	[---]
Province/Territory and Postal Code Information:	[---]

11. Telephone number

[2064401938]

12. Alternate Telephone number

[2066123913]

13. Email Address

[mrfsys@gmail.com]

Page 2 of 3

Application for Summer-Only Admission Application fee: $60.00, Page 3 of 3
Citizenship and Washington Residency Information
14. Birthplace
City:	[Worcester]
State:	[Massachusetts (MA) ]
Country:	[United States (US) ]

15. Are you a U.S. citizen?	[ ] Yes: skip to #18 [X] No: continue with #16-17

16. Non-U.S. Citizens Only
What is your country of citizenship?	[United States (US) ]
What is your country of permanent residence?	[United States (US) ]

17. Immigration Information
Current or Expected Visa Type or Immigration Status:	[Other: any status not included above]
Resident Alien Number:	[---]
Visa Type and Number:	[---]
Date issued or will be issued:	[---](mm/yyyy)
Date your visa became (or will become) effective:	[---](mm/yyyy)

18. Washington State Residency
Are you a resident of Washington State?	[X] Yes [ ] No

If you answer yes, you must include dates of your most recent continuous residence in Washington.
From:	[03-2008](mm/yyyy)
To:	[05-2015](mm/yyyy)

Ethnicity
19. Are you of Hispanic or Latino origin? (Check all that apply.)
[ ] I choose not to respond [X] No [ ] Yes, Mexican or Mexican American or Chicano [ ] Yes, Puerto Rican [ ] Yes, Other Hispanic or Latino [---]Specify, e.g., Argentinean, Colombian, Nicaraguan, Salvadoran, Spaniard, etc.

20. What race(s) do you consider yourself? (Check all that apply.)
[ ] African American or Black [ ] Alaska Native or American Indian [---]Specify tribal/corporate affiliation; verification recommended
Asian American[ ] Asian Indian [ ] Cambodian [ ] Chinese [ ] Filipino [ ] Hmong [ ] Indonesian [ ] Japanese [ ] Korean [ ] Laotian [ ] Malaysian [ ] Pakistani [ ] Singaporean [ ] Taiwanese [ ] Thai [ ] Vietnamese [ ] Other Asian American [---]Specify
Pacific Islander[ ] Fijian [ ] Guamanian or Chamorro [ ] Mariana Islander [ ] Melanesian [ ] Micronesian [ ] Native Hawaiian [ ] Samoan [ ] Tongan [ ] Other Pacific Islander [---]Specify
[X] White or Caucasian (European, Middle Eastern, or North African)
[ ] Some other race [---]Specify
[ ] I choose not to respond

Signature
In pledging to this form, I certify that to the best of my knowledge that statements I have made in this application are complete and true. I hereby give permission to release any academic records requested by the University of Washington. I acknowledge that failure to disclose and submit official transcripts from all schools, colleges, or universities attended and failure to disclose and submit complete and accurate information may result in the denial of admission or subsequent dismissal from the University of Washington. I understand that my application is incomplete without my pledge below. [X] I Agree Date[05-20-2015](mm/dd/yyyy)
Nondiscrimination Policy
The University of Washington reaffirms its policy of equal opportunity regardless of race, color, creed, religion, national origin, sex, sexual orientation, age, marital status, disability, or status as a disabled veteran or Vietnam era veteran. This policy applies to all programs and facilities, including, but not limited to, admissions, educational programs, employment, and patient and hospital services. Any discriminatory action can be a cause for disciplinary action. Discrimination is prohibited by Presidential Executive Order 11246 as amended, Washington State Gubernatorial Executive Orders 89-01 and 93-07, Titles VI and VII of the Civil Rights Act of 1964, Washington State Law Against Discrimination RCW 49.60, Title IX of the Education Amendments of 1972, State of Washington Gender Equity in Higher Education Act of 1989, Sections 503 and 504 of the Rehabilitation Act of 1973, Americans with Disabilities Act of 1990, Age Discrimination in Employment Act of 1967 as amended, Age Discrimination Act of 1975, Vietnam Era Veterans' Readjustment Assistance Act of 1972 as amended, other federal and state statutes, regulations, and University policy. Coordination of the compliance efforts of the University of Washington with respect to all of these laws and regulations is under the direction of the Assistant Provost for Equal Opportunity, Dr. Helen Remick, Equal Opportunity Office, Box 354560, 4045 Brooklyn Ave., N.E., University of Washington, Seattle, Washington, 98105-6261, telephone (206) 685-3263/V or 543-6452/TTY.
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