Return all Items to: Admissions Office / Florida Memorial University 15800 N.W. 42nd Ave. Miami Gardens, Florida 33054 (305) 626-3600 www.fmuniv.edu
Admissions Form / part 1
…….Admissions Application
Applicant Information (Please Print Clearly)
Term /Year of Entrance Location
Main Campus Off Campus Site
Name (Last, First, Middle) Social Security Number
Street address
City State
Zip
Home Phone ( )
Application Status
First Time Transfer Re-admit Other
Gender* (optional) Age * (optional) BIRTHDATE (m/d/y) Marital Status* Ethnic Origin* (optional)
Nation of Birth Nation of citizenship (if different than Birth)
Scholastic Information
High School Attended CEEB# CITY STATE ZIP
High School Phone Date of Graduation (M/D/Y) Estimated Grade Point Average High School Equivalency (GED) Intended Major S.A.T. Verbal S.A.T. Quantitative A.C.T. Math A.C.T. English A.C.T. Reading
Other Information
Do You plan to live on campus? Yes No Do you plan to apply for financial Aid? Yes No Incase of an emergency, contact: Relationship to applicant Phone
( )
Street Address City State Zip
Transfer Students only (If you’ve attended more than three schools, list additional information on reverse side)
College/University Address City/State Year(s) Of Attendance
Have you ever been placed on Academic or School Probation? Yes No If yes, explain briefly:
Have you ever been convicted or found guilty of violation any federal, state or local law/ ordinance other than a traffic violation? Yes No If yes, explain briefly:
How did you hear About Florida Memorial University?
Radio TV Mailing School Counselor Newspaper/Magazine Other
Referred to Florida Memorial University By: Address Phone
I certify that the above information I have provided is accurate
Signature Date
Return
All Items to: Admissions Office Florida Memorial University 15800 NW 42nd Avenue Miami, Florida 33054 305.626.3751 800.822.1362 www.fmuniv.edu 305.623.1462 Fax Number
Prospective student
:
Please complete the required information below ands forward it to your high school or College. If
you need additional Transcript Release forms, photocopy this one.
Request is herby made for the release of my official transcript and test scores in order to complete
the admissions process at Florida Memorial University.
School Information
High School Name
Street address City State Zip
Student Information
Applicant Name Social Security Number
Permanent Address City State Zip
BirthDate (M/D/Y) Date of last Attendance Student Signature
Admission Forms / part 2
Official Transcript
Admission Forms / part 3
Letter Of
Recommendation
Return All Items to: Florida Memorial University 15800 NW 42nd Avenue Miami, Florida 33054 Miami, Florida 33054 305.626.3751 305.626.3751 800.822.1362 800.822.1362 www.fmuniv.edu www.fmuniv.edu 305.623.1462 Fax Number
Applicant Name (Last, First, Middle) Social Security Number
Street Address City State Zip
Recommender Name (Last, First, Middle) Phone
( )
Street Address City State Zip
Relationship to the Applicant:
Teacher Guidance Counselor Pastor Other
Please indicate what you know about Applicant’s background: His/her family circumstances, home
environment, neighborhood and any other information relating to his/her background.
Please sate Applicant’s attitude toward education, his/her specific strengths, weakness,
achievements and other relevant scholastic information. We are also interested in your assessment of the
Applicant’s level of motivation and capacity for hard work.
Return All Items to: Admissions Office Florida Memorial University
Admission Forms / part 4
Personal Statement
15800 NW 42nd Avenue Miami, Florida 33054 305.626.3751 305.626.3751 800.822.1362 800.822.1362 www.fmuniv.edu www.fmuniv.edu 305.623.1462 Fax NumberName (Last, First, Middle) Social Security Number
Street Address City State Zip
Phone ( )
School Name
On this page we would like you to tell us something about yourself. Without asking for an
autobiography, we would like to learn a little more about the experiences and thoughts that have
made you the person you are. Most of the contents of an admissions folder are either facts or
judgments made by those who have known or worked with you. In addition, we found it helpful
to read some of your own comments.
We asked you to accept one condition as you write: do not consult with anyone in this preparation
or show anyone your statement before mailing it to us. You may use written sources to check the
correctness of your writing or you may refer to work you have read. Your signature at the end of
this page will indicate that you wish us to accept the writing as your own. If you wish, you may
use extra pages.
Return All Items to: Admissions Office Florida Memorial University
Admission Forms / part 5
Medical Information
15800 NW 42nd Avenue Miami, Florida 33054 305.626.3751 800.822.1362 www.fmuniv.edu 305.623.1462 Fax Number Please Fill out Student Information section and forward to you physicianApplicant Name(Last, First, Middle) Birth Date (M/D/Y) Phone ( )
Street address City State Zip
In case of an Emergency, contact: Relationship to Applicant Phone ( )
Street Address City State Zip
Social Security Number
Medical History
List any Allergies or Drug Sensitivities
List/Describe Any Hospitalizations and/or operations Is there any History of the
following conditions in your family If so, indicate who. M=mother, F=Father,
Anemia Asthma Diabetes Eczema Epilepsy Hay fever
U=Uncle, A=Aunt, S=Sister, B=Brother,
GM=Grandmother, GF= Grand father, C=Cousin
Heart Disease High Bld. Prsr. Mental Illness Migraines Nerv. Disorder Tuberculosis
Height Weight Eyes Left Right Ears Nose Mouth
Throat Tonsils Neck Chest/Lungs Heart/Pulse
Anemia Abdomen Spine/Back Diabetes Hypertension Extremities
From a Physical and medical point of view, do you
consider the applicant able to enroll in a collegiate
program and to participate in sports and recreation?
Yes No If no please explain:
___________________________________
OB-GYN History Urinalysis
Age of Menarche Date of I.M.P. Reaction SP. GR. ALB. Sugar Hematocrit HgB
Number of Pregnancies Births Date of last Pap Smear (M/D/Y)
Chest X-Ray
Tine Test or Manoux
Positive Negative Date Positive Negative Date
Immunization
Tetnaus / Date: Small Pox/Date: Polio/Date: MMR #1/Date: MMR #2/Date:
Doctor’s Street Address City State Zip
Doctor’s Name (Please Print) Doctor’s Signature Doctor’s Phone ( )
