Non-Degree Certificate Application - Mansfield University of Pennsylvania

For students seeking to take MU courses to complete a non-degree certificate.

Step 1: About You

Personal Information

First Name

Middle Name

Last Name

Suffix

Preferred First Name (ONLY if different from your Legal First Name)

Email Address

Home Phone

(

)

Cell Phone

(

)

I give permission to Mansfield University to send me important updates via text messaging. (Standard message charges apply.)

Date of Birth

Sex

Gender

Social Security Number

Do you have any previous names?

Yes

Required!

Please list any previous names you've had.

Name Type

First Name

Last Name

Name Type

First Name

Last Name

Name Type

First Name

Last Name

Name Type

First Name

Last Name

How did you hear about Mansfield University?

Required!

Please specify.

To whom should we send information?

One Parent/Guardian

Both Parents/Guardians

Only Me

Required!

Your Permanent Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Is your mailing address the same as your permanent address?

Yes

Required!

Your Mailing Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Address Effective Until

Parent 1/Guardian 1

Relationship

Specify Other

Title

First Name

Last Name

Suffix

Email Address

Phone Number

(

)

Phone Type

Please send my parent/guardian important updates via text messaging. (Standard message charges apply.)

Is this parent's/guardian's address the same as your permanent address?

Yes

Required!

Parent 1/Guardian 1 Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Parent 2/Guardian 2

Relationship

Specify Other

Title

First Name

Last Name

Suffix

Email Address

Phone Number

(

)

Phone Type

Please send my parent/guardian important updates via text messaging. (Standard message charges apply.)

Is this parent's/guardian's address the same as your permanent address?

Yes

Required!

Parent 2/Guardian 2 Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Emergency Contact Information

Name

Relationship

Home Phone (US only)

Cell Phone (US only)

Foreign Telephone Number

Citizenship

Citizen Type

U.S. Citizen

Permanent Resident

Not a U.S. Citizen or Permanent Resident

Required!

Stop!

You cannot submit this application. You must be a US Citizen or Permanent Resident to be PA certified.

What is your country of citizenship?

What is your country of birth?

Alien Registration Number

What is your visa status?

Are you currently in the United States?

Yes

Required!

When did you enter the United States?

Is English your primary language?

Yes

Required!

What is your primary language?

Ethnicity (Optional)

If you wish to be identified with a particular ethnic group, please select the choice that most accurately describes your heritage. No information you provide will be used in a discriminatory manner.

Are you Hispanic or Latino?

Select one or more of the following races:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Step 1: About You

Personal Information

Your Permanent Address

Your Mailing Address

Parent 1/Guardian 1

Parent 1/Guardian 1 Address

Parent 2/Guardian 2

Parent 2/Guardian 2 Address

Emergency Contact Information

Citizenship

Stop!

Service

Ethnicity (Optional)