Student Application

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Institute name*

Student ID number (office use only)

Admissions number (office use only)

Intended major area of study

Social Security number*

Sex*

Female

Male

First name*

Last name*

Date of birth*

Month

Day

Year

Phone*

Email address*

Applicant Address

Country/Region*

Address*

Address - line 2

City*

Zip / Postal code*

United States citizenship*

Yes

No

Previous application to VHD*

Yes

No

Felony conviction*

Yes

No

Continuous Wisconsin residency for the past 12 months*

Yes

No

Ethnic origin (Optional)

White/Caucasian

American Indian

Black/African American

Hispanic/Latino

Alaska Native

Asian

Other

Education History

High school name*

High school address*

High school from date*

Month

Day

Year

High school to date*

Month

Day

Year

High school graduation*

Yes

No

High school degree*

College name*

College address*

College from date*

Month

Day

Year

College to date*

Month

Day

Year

College graduation*

Yes

No

College degree*

Other education details (Name, address, dates, graduation, and degree)

Reference Information

Reference full name*

Reference relationship*

Reference phone*

Reference address*

Previous employment (Company, phone, address, supervisor, title, salary, dates, and reason for leaving)*

Permission to contact supervisor *

Yes

No

Previous employment (Company, phone, address, supervisor, title, salary, dates, and reason for leaving)*

Permission to contact supervisor *

Yes

No

Military Service

Military branch

Military from date

Month

Day

Year

Military to date

Month

Day

Year

Rank at discharge

Type of discharge

Honorable

Other

I certify that my answers are true and complete to the best of my knowledge. If this application leads to enrollment, I understand that false or misleading information in my application or interview may result in my release.

Signature*

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Date signed*

Month

Day

Year

Application Fee

$55

Application fee is non-refundable.

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