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  • Full Legal Name: *
  •  
  • Main Phone * - -
  • Work Phone - -
  • Mobile Phone - -
  • Marital Status *
  • Gender *
  • Emergency Contact *
  • Emergency Contact Phone Number 1 * - -
  • Emergency Contact Phone Number 2 - -
  • Degree & Certificate Programs of Interest *
  • Time of Day *
  • Start Date * / / Pick a date.
  • Do you have a high school diploma or GED? *
  • Citizenship *
  • Ethnic Identity *
  • Veteran *
  • Employment Data

  • Previous Education or Training

  • Previous Education or Training - Part 2

  • Previous Education or Training - Part 3

  • Can you provide a health certificate stating that you are free of communicable disease? *
  • All information provided is true and complete to the best of my knowledge. I understand that admission to the University of Antelope Valley is contingent upon submission of one of the following: official high school transcript, official G.E.D. test scores and satisfaction of any additional admission criteria. *