3+3 OTD Program Confirmation

About You

First Name

Middle Name

Last Name

Other names that may appear on educational records

Email Address

Home Telephone Number

Mobile Telephone Number

Mailing Address

Country

Street

City

Region

Postal Code

Permanent Address

Same as Mailing Address

Country

Street

City

Region

Postal Code

Birthdate

Gender

If you would like the opportunity, we invite you to share more about your gender identity.

Employer

Work Telephone

Country of Citizenship

Social Security Number

Are you a U.S. Permanent Resident?

Yes

No

Place of Birth

City of Birth

Colleges and universities are asked by many groups, including the federal government, accrediting associations, college guides, and newspapers, to describe the ethnic/racial backgrounds of their students and employees. In order to respond to these requests, we ask you to answer the following two questions.
View Definitions

Are you Hispanic or Latino?

Yes

No

Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:

Are you a U.S. Veteran?

Yes

No

Your Plans

Please confirm your program of study:

Entry term:

Select applicable college:

Time Status:

Housing Preference:

T shirt size (unisex):

If you enroll in our program, what is the name you would like on your professional name badge?

Education

Please list all colleges or universities attended.

College (Type name and select from list)

School CEEB

Date of Graduation (i.e MM/YYYY)

Date From (i.e MM/YYYY)

Date To (i.e MM/YYYY)

Degree Awarded:

College (Type name and select from list)

School CEEB

Date of Graduation (i.e MM/YYYY)

Date From (i.e MM/YYYY)

Date To (i.e MM/YYYY)

Degree Awarded:

College (Type name and select from list)

School CEEB

Date of Graduation (i.e MM/YYYY)

Date From (i.e MM/YYYY)

Date To (i.e MM/YYYY)

Degree Awarded:

Additional Information

Have you ever been suspended, dismissed or expelled from any educational institution?

Yes

No

Have you ever been convicted of a felony (without the record being sealed or expunged)?

Yes

No

If you answered "Yes" please provide an explanation below.

I, the undersigned, acknowledge that by signing this application form, I am hereby responsible for any and all tuition, fees, and other charges incurred during my enrollment at Western New England University. Furthermore, I understand that any and all payment terms must be satisfied before the beginning of each academic session, and that failure to do so may prevent me from being able to register at Western New England University for future sessions. I also understand that finance charges will accrue on any and all unpaid balances. Lastly, I understand that I will be financially responsible for all costs related to collection of any and all unpaid balances, including but not limited to attorney fees, collection costs, and further interest. I understand the application fee is not refundable for any reason.

I certify the information contained within is complete and correct to the best of my knowledge, and that I am the original author of any information that is directly requested of me. I understand that my acceptance and matriculation may be canceled if any information in support of my application is found to be false.

In place of your signature, please type your full legal name:

Submitted Date