CNSE Undergraduate Intake Form

First Name

Middle Name

Last Name

Birthdate

Gender

Female

Male

X

Mobile Phone

Email Address

Permanent Home Mailing Address

Country

Street

City

Region

Postal Code

Temporary Mailing Address

Country

Street

City

Region

Postal Code

Mailing Address type

Expiration of temporary address

Are you a New York State Resident?

Yes

No

County of Residency:

Number of Months as a NYS Resident:

Are you Hispanic/Latino?

Yes

No

Please indicate your race (select one or more)

Have you been dismissed, expelled, and/or suspended from a college for disciplinary reasons?

Yes

No

High School Name

High School CEEB

High School Level

High School Address

Country

City

Region

Postal Code

Enter date of High School Graduation, High School Withdrawal or completion of high school equivalency diploma.

Indicate whether you are applying as a Freshman or a Transfer student.

First-Year

Transfer

Country of Birth

Country of Citizenship

Current visa type (if applicable)

Visa Expiration Date