University of Bridgeport

APPLICATION FOR READMISSION

Name____________________________________________ Phone_____________________

Address_____________________________________________________________________

City____________________________________ State________________ Zip____________

Student #______________ S.S. #______________ Academic Program_____________

Term planning to attend:  Fall_______ Spring_______ Summer_______ Year: 20________

If you have changed your name, indicate the name under which you previously attended:

___________________________________________________________________________

Are you presently or have you enrolled at any college/university since you left U.B.? 

Yes_______ No_______

If yes, list schools attended since last enrollment at U.B.: ___________________________

___________________________________________________________________________

(Submit official transcripts from each)

Signature________________________________________ Date______________________

Please send completed form to:

Office of the Registrar

University of Bridgeport

126 Park Avenue

                                                             Bridgeport, CT 06604

DO NOT WRITE BELOW THIS LINE UNTIL ACTION HAS BEEN TAKEN

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ACTION ON APPLICATION FOR READMISSION

Clearance must be obtained from the following offices.

___________________________________            ___________________________________

Registrar                                                      Date                          Bursar                                                           Date        

___________________________________            ___________________________________

Academic Dean/Director                                            Date             Dean of Students                                        Date

State any conditions or stipulations pertinent to readmission: _______________________

____________________________________________________________________________

Admission Granted: ____________________ Denied: _________________

Fall __________ Spring ___________ Summer ________ Year: 20________  

03/2005