Application for Non-Degree/Licensure Only Status or Carolina University Applicants

Legal Name

First Name

Preferred First Name

Middle Name

Last Name

Maiden/Former Name

Email Address

Home Address

Country

Street

City

Region

Postal Code

Home Phone:

Is your Mailing address the same as your Home address?

Yes

Mailing Address

Country

Street

City

Region

Postal Code

Demographics

Birthdate

Sex

Female

Male

Ethnicity

Citizenship

US Citizen or Permanent Resident?

Current Visa Type:

Enrollment

Beginning Date:

Program

Select the specific residency program that you are applying for from the below options (choose only one):

Licensure Status:

District:

Additional Notes:

Education

School

Start Date

End Date

Degree

Eligible to Return:

Yes

Do you have another school to enter?

Yes

School

Start Date

End Date

Degree

Eligible to Return:

Yes