Queens College - Center for the Biology of Natural Systems - CUNY

GRADUATE NON-MATRICULANT APPLICATION
Application For: ڤ Fall ڤ Spring ڤ Summer Session I/II Year 20________
Name of applicant: ڤ Mr. ڤ Ms. _____________________________________________________________________________
Last (family name) First (given name) Middle
Any prior last name used: ______________________________________________________________________________________
Social Security or ID #: _____-____-________ Gender: ڤ Male ڤ Female
Date of birth: _______________
Month/Day/Year
Permanent Address: _________________________________________________________________________________________
House # Street Ap.t#
___________________________________________________________________________________________________________
City County State Zip code Country
Telephone: Day (_______)_________________________
Area code
E-mail address: __________________________________
Length of time at the above address: _________ ____________
Country of Birth: ____________________
Evening (______)_________________________
Area code
Portfolio URL: ___________________________
Length of time in New York State: __________ __________
Years Months Years Months
Are You a U.S. citizen ڤ Yes ڤ No (please indicate status below)
Immigration status: ڤ Permanent resident ______________________________
Alien Registration #
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Date of entry on card
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Visa _____________________ ___________________ ____________________ Specify type Date obtained Expiration date
Have you taken graduate courses at Queens College ڤ Yes ڤ No
In what department are you planning to take classes _________________________________________________________________
Note: Department approval is required for non-matriculated admission. Please have this form signed by the appropriate departmental
advisor/representative.
____________________________________________________________________________________________________________
Signature of Graduate Advisor/Representative Print Name Date
Academic Record: Please report names of institutions and dates degrees were conferred
Bachelor's degree from
Master's degree from
Ph.D. degree from
Other degree (specify) from
______________________________________________________________________
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Certification: The statements made in this application are true and complete to the best of my knowledge and belief.
Signature ___________________________________________________________________ Date _________________________
Queens College of the City University of new York does not discriminate on the basis of age, sex, color, creed, national origin,
physical or mental disability, sexual orientation marital status, alienage, or citizenship status, or veteran's status, the college will
comply with Title IX of the Educational Amendments Act of 1972, which protects persons from discrimination on the basis of sex in
the operation of its educational programs or activities, inquiries should be directed to the
Affirmative Action Coordinator, Kiely Hall, Queens College, Flushing, NY 11367-1597
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Division Billing Adm. code Group FINTP RESDE "ON LINE"
Queens College, CUNY, Office of Graduate Admissions, 65–30 Kissena Blvd, Flushing NY 11367–1597 | (718) 997 - 5200 Rev 7/03