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Graduate College SPECIAL STATUS APPLICATION 200 Prospect Street Zimbar-Liljenstein Rm 154 East Stroudsburg PA 18301-2999 570 422-3536 Email grad po-box. esu. edu Please Note Students must apply to a program before the completion of 12 credit hours. Courses completed as a Special Status student will not automatically be applicable toward a degree or certification program. Students must provide an undergraduate transcript indicating the degree conferral date Please print Last Name First Name Mailing Address City Other Phone Gender Middle State Zip Code Date of Birth Former Name County Home Phone Email Address Please list all institution s of higher education you have attended Institution City/State Dates Attended Do you meet Pennsylvania residency requirements Yes No Did you obtain your undergraduate degree from ESU Veteran Status Veteran Non-veteran IN CASE OF EMERGENCY PLEASE NOTIFY Parent Spouse Partner Other specify Major/Minor Degree/Certification Obtained Date of Graduation Semester and year you intend to enroll Fall August Spring January Year Summer Session Ethnic Background White Hispanic/Latino Black/African/American Asian American Indian/Alaskan Native Native Hawaiian/Pacific Islander Last First MI Address Zip Area Code Phone Number I certify that these statements are true and correct to the best of my knowledge. Graduate College SPECIAL STATUS APPLICATION 200 Prospect Street Zimbar-Liljenstein Rm 154 East Stroudsburg PA 18301-2999 570 422-3536 Email grad po-box. esu. edu Please Note Students must apply to a program before the completion of 12 credit hours. Courses completed as a Special Status student will not automatically be applicable toward a degree or certification program* Students must provide an undergraduate transcript indicating the degree conferral date Please print Last Name First Name Mailing Address City Other Phone Gender Middle State Zip Code Date of Birth Former Name County Home Phone Email Address Please list all institution s of higher education you have attended Institution City/State Dates Attended Do you meet Pennsylvania residency requirements Yes No Did you obtain your undergraduate degree from ESU Veteran Status Veteran Non-veteran IN CASE OF EMERGENCY PLEASE NOTIFY Parent Spouse Partner Other specify Major/Minor Degree/Certification Obtained Date of Graduation Semester and year you intend to enroll Fall August Spring January Year Summer Session Ethnic Background White Hispanic/Latino Black/African/American Asian American Indian/Alaskan Native Native Hawaiian/Pacific Islander Last First MI Address Zip Area Code Phone Number I certify that these statements are true and correct to the best of my knowledge. Signature Date NOTICE OF NON-DISCRIMINATION East Stroudsburg University of Pennsylvania does not discriminate on the basis of race color religion national origin sex veteran status disability or age in its programs and activities in accordance with state and federal laws The following person has been designated to handle inquiries regarding this policy Director of Diversity/Ombudsperson 200 Propect Street 115 Reibman Building East Stroudsburg PA 18301 570-422-3656.