University College Community - Request to Affiliate with UCC

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Please complete this form in its entirety. Should you encounter an error please e-mail: ucc@rci.rutgers.edu.

If you'd rather download the form, fill it out manually and fax (732-445-3519) or mail it back to us, then click here.

Demographic Information

An undergraduate student enrolled in one of the schools at Rutgers-New Brunswick/Piscataway is eligible to affiliate with, and utilize the programs and services offered by, the University College Community if he or she meets one or more of the following criteria. Please check all that apply:

	has been out of high school for 4 or more years at the time of application to Rutgers-NB or at time of first registration.
	is returning to school after an absence from college or university environment.
	is part-time taking fewer than 12 credits for 2 semesters or more.
	has had an interruption (typically 2 years or more) of formal undergraduate education either at Rutgers or before attending Rutgers.
	has significant non-academic commitments, for example, documented issues pertaining to work, family, mental or physical health, or finances that would preclude or severely impede a student from obtaining a degree through traditional academic full-time study. Please explain (supporting documentation will be needed):

	is not enrolled in a degree program (non-matriculated).
	is pursuing post-baccalaureate studies primarily in undergraduate courses.

Check semester and year of admission to Rutgers:

Fall

Spring

Name:

Address:

Phone Number(s):

E-mail Address:

RUID:

Academic Information

School of Enrollment at Rutgers :

Degree Credits Earned:

Credits Completed at Rutgers:

Cumulative GPA:

Major GPA:

Major/Intended Area of Study:

Minor (if applicable):

Reason for joining the UCC:

I declare that all information provided is true, accurate and complete. This form must be signed with your e-mail address if you're filling it out online.

Signature:

Date:

All information provided on this form and supporting documents will be kept confidential.