Student Application

Please give an address at which you wish to be contacted throughout the school year.

First Name *

Last Name *

Date of Birth *

Address *

Address

Mailing Address

Physical Address

City

State/Province

Zip/Postal

Country

Phone *

Email *

Are you a UIC Shareholder? *

Yes

Are you a descendant of a UIC Shareholder? *

Yes

If yes, please enter the UIC Shareholder's full name. *

Relationship with UIC Shareholder:

Student is: *

Full-time (More than 12 credits)

Part-time (Less than 12 credits)

Academic scholarship term applying for: *

Academic School Year *