Readmit Application



Student Information

Mr. Ms.   *First    Middle    *Last    Suffix:

Previous Name: Last First Name:


Social Security No.: (xxx-xx-xxxx)
The Federal Privacy Act of 1974 requires that you be notified that disclosure of your Social Security Number is voluntary and is not required to determine admission. Your Social Security Number will be used to match your application with your SAT/ACT Test Scores and/or Financial Aid information so failure to provide it may affect your eligibility for financial aid and may delay decision of admission. Your Social Security number is also used to report your educational expenses to the Internal Revenue Service to verify any education-related deductions you may claim on your federal income taxes.


*Gender: Male   Female      *Date of Birth (mm/dd/yyyy*): *Please enter a 4 digit year


Home Phone: (xxx-xxx-xxxx)       *Cell Phone Number: (xxx-xxx-xxxx)


PA, NJ, NY County: If other, Name of County:

*Legal Address:

*City:    *State:   *Zip Code:

*Email Address:


Emergency Contact:

*Name: *Phone:

Relationship (parent, guardian, spouse):


Family Information:

Name of Father:   

Name of Mother:   


Legal Address for Parent/Guardian:

City: State: Zip Code:



For Veterans:
Date of Service (mmyy)- From To Branch of Service:


*Are you a United States Citizen?: Yes   No

Are you a permanent Resident Alien (i.e., "Green Card" holder)? Yes  No

If you answered "No" to this question, you will not be able to submit this application. Please fill out the
International Application instead.



*Semester you wish to enroll in at Mansfield University:

*Enrollment Status: Full-Time Part-Time (less than 12 credits)


*Name of Program you are interested in:

If you plan to be a music major, list instrument/voice:

If an art major, first medium:


*Has any member of your immediate family graduated from Mansfield University? Yes No

If yes, Name: Relationship: Year of Graduation:


Readmit Information

List the dates that you were previously enrolled at Mansfield:

Post-secondary institutions attended since last enrolled at MU:

List Name / CEEB code* / Location / Dates of Attendance * / Full or Part-time for each institution in the order of attendance:
*(Collegeboard CEEB Search)
*Please enter a 4 digit year


CEEB code*


From (mmddyyyy*)

To (mmddyyyy*)

Full or
Part time

Type of Institution

2 Yr. College/Univ.
4 Yr. College/Univ.

2 Yr. College/Univ.
4 Yr. College/Univ.

2 Yr. College/Univ.
4 Yr. College/Univ.

What was your previous major?


Ethnic/Racial Identification:

We ask each applicant to provide information about his/her ethnic & racial background. We use this information solely to help us in determining whether the university is being successful in its efforts to assure equal opportunities to all persons. Please select the appropriate ethnic/racial identification below:

What is your ethnicity?
Hispanic or Latino
Not Hispanic or Latino

What is your race? Mark one or more races to indicate what you consider yourself to be:
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Black or African American




Questions or Comments, Contact Ruth Hermansen or call 570-662-4204.