UNIVERSITY OF HAWAI‘I

System Application Form Academic Year 2016–2017

PLEASE TYPE OR PRINT CLEARLY IN INK. COMPLETE BOTH SIDES OF THIS FORM, DETACH, AND SUBMIT TO THE CAMPUS ADMISSIONS OFFICE. TO APPLY ONLINE, VISIT www.hawaii.edu/admissions

SEMESTER ENTERING SOCIAL SECURITY NUMBER LEGAL NAME: LAST/FAMILY FIRST/GIVEN FULL MIDDLE ANY OTHER NAMES USED
SUMMER ON TRANSCRIPTS, ETC.
FALL
SPRING __ __ __ / __ __ / __ __ __ __

CURRENT MAILING ADDRESS: NUMBER STREET CITY OR PROVINCE STATE OR COUNTRY ZIP/POSTAL CODE UNTIL PHONE
month/day/year (home)

(cell)

PERMANENT MAILING ADDRESS: NUMBER STREET CITY OR PROVINCE STATE OR COUNTRY ZIP/POSTAL CODE
(work)

GENDER BIRTHDATE BIRTHPLACE CITIZENSHIP NON-US CITIZEN—VISA TYPE (attach copy of green card, if any)
month/day/year (state or foreign country) STUDENT VISA
FEMALE USA
OTHER ________________________________________ Permanent Resident—DATE REC ___________________________
MALE __ __ /__ __ /__ __
(specify country) OTHER (specify) ________________________________________
WERE ANY OF YOUR ETHNICITY (check one) RACE (check one or more) See instructions for listing E-MAIL ADDRESS
ANCESTORS HAWAIIAN? Hispanic or Latino AA AI CA CH FI GC HW IN JP
Yes No Not Hispanic or Latino KO LA MC OA OP SA TH TO VI

NAME OF HIGH SCHOOL GRADUATED/WILL GRADUATE FROM CITY STATE/COUNTRY MONTH/YEAR GRADUATED/WILL GRADUATE
___ ___ / ___ ___

LIST EVERY COLLEGE, UNIVERSITY, BUSINESS AND POST-SECONDARY SCHOOL ATTENDED, INCLUDING ANY UH CAMPUS, AND THE ONE YOU ARE CURRENTLY ENROLLED IN, IF ANY.
NAME OF INSTITUTION CITY/STATE ATTENDED/ ATTENDING NAME OF MONTH/YEAR
(Do not use abbreviations) Attach additional sheet if necessary OR FROM THROUGH DEGREE, DIPLOMA, EXPECTED OR
MAJOR
LIST MOST RECENT FIRST CITY/COUNTRY MONTH/YR MONTH/YR OR CERTIFICATE RECEIVED

___ ___ /___ ___

___ ___ /___ ___

___ ___ /___ ___

___ ___ /___ ___

___ ___ /___ ___

COMPLETE THIS SECTION IF YOU ARE CURRENTLY ENROLLED IN A COLLEGE OR UNIVERSITY (attach additional sheet if necessary).
NAME OF COLLEGE OR UNIVERSITY CURRENTLY ATTENDING LOCATION (CITY/STATE) TERM/YEAR CURRENTLY ENROLLED IN

COURSES CURRENTLY ENROLLED IN

COURSE TITLE DEPARTMENT COURSE NO. CREDIT HOURS
Example: World Civilization I History 151 3 sem hrs

IF YOU HAVE PREVIOUSLY APPLIED FOR ADMISSION TO A UH CAMPUS, INDICATE THE SEMESTER, YEAR, AND DECISION TAKEN. DO YOU PLAN TO ATTEND:
DAY CLASSES EVENING CLASSES BOTH
CAMPUS APPLIED TO __________________________________________ SEMESTER/YEAR __________________ ACCEPTED NOT ACCEPTED

LIST YOUR CHOICE OF CAMPUSES, MAJORS, AND CERTIFICATES/DEGREES YOU ARE SEEKING.
CAMPUS MAJOR CERTIFICATE/DEGREE

Kapiʻolani Community College

1. _____________________________________________________________ _________________________________________________________________________________ _________________________

2. _____________________________________________________________ _________________________________________________________________________________ _________________________

APPLICANT'S CERTIFICATION
I certify that the responses provided on the System Application Form are complete and true to the best of my knowledge and belief. I understand that providing incomplete, incorrect,
or false information may result in the rescission or denial of my admission and subject me to the requirements and/or disciplinary measures as provided under the University's Student
Conduct Code. I agree to produce certified documents relative to the determination of my residency status upon request and that the provision of incorrect information regarding my
residency declaration will also subject me to the requirements and/or disciplinary measures provided for in the University's rules and regulations governing the determination of residency
for admission and tuition purposes. Further, I understand that the UH System shares a common database and information pertaining to me may be accessed by all UH campuses.

Date ________________________________ Signature ___________________________________________________________________________

FOR OFFICE USE ONLY

ID TUITION STATUS FEE PAYMENT
__ __ __ __ __ __ __ __ Rec'd ______________________________________ #__________________________ By ___________________________