University of California, Berkeley
Undergraduate Application for Readmission

PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM.
You may fill in the form, then print a copy.  If you have problems, print a blank copy, then fill it in.
Please also be sure to fill out an SLR Form.

Term for which you are reapplying: Fall  20   Spring 20
UC Berkeley SID             Birth Date:(mm/dd/yy)             Sex:      M      F
Name: Last First Middle
Former Name: Last First Middle

If you were registered at Berkeley under a different name please visit
http://registrar.berkeley.edu/Records/namechng.html for instructions.

Email:

Current Phone: Perm. Phone:
Mailing Address: Street: City: State: Zip:
Permanent Address: Street: City: State: Zip:
First Enrolled at Berkeley: Fall     Spring      Summer           Year 
Last Enrolled at Berkeley: Fall     Spring      Summer           Year 
School/Major Enrolled at Berkeley: School/College  Major
School/Major to which you are reappyling: School/College  Major

Degree for which you are reapplying:     Bachelor's Degree    Second Bachelor's Degree    Limited Status Program
I have not attended/am not attending another institution while absent from Berkeley.
I have not attended/am not attending the Education Abroad Program (EAP) at Berkeley.
If you have attended/are attending another college or university since your enrollment at Berkeley, please provide the following:
Institution: City: State: Zip:
Dates:   From:   To:    
Institution: City: State: Zip:
Dates:   From:   To:    
I have /am attending a non-UC Education Abroad Program.

 

Applicant's Signature:___________________________________________________Date:_______________

Dean or Dean's Representative:_______________________________________________Date: _______________
  (Dean's Approval required for all students)
   FOR OUA USE ONLY:
   Date Received:______________  Level:___________________________________  Date Coded:______________
   Blocks: __No    __Yes Res. Code: __R    __N    __P    __S    __L   


Office of Undergraduate Admissions, 110 Sproul Hall MC 5800, University Of California, Berkeley, Berkeley, CA 94720-5800  
rev. 12/2007