Application for UC "New Berlin Program"
(Print and mail or bring form to the address below)Please Print Clearly
Name _________________________________________________________ ______ - ____ - ______
Last First Middle Student ID#Present (academic) address ______________________________ Tel: ( ) ______________
_______________________________ _____ ______________ Email: __________________________
City State ZipHome Address ________________________________________ Tel: ( ) ______________
______________________________ ____ ______________
City State ZipUse home address in case of an emergency? Yes ______ No _______
If NO, write emergency address here:_____________________________________________________
_____________________________________________________Tel: ( ) ______________
Name of person at that address to contact in case of an emergency
___________________________________________ relationship: ________________________
College that you are now attending: _________________________________________________
Major(s)/Minor ________________________________________________________________
Present academic class standing: Freshman ____ Soph. ____ Junior ____ Senior ____ Other ____
Current GPA: ______________
Even though the Berlin Program is taught in English, please indicate your previous training in German.
Date: __________________ Signature: _____________________________________________
Please return completed form to:
Director "New Berlin Program"
733 Old Chemistry Bldg.
Cincinnati, OH 45221-0372
Fax: (513) 556-1991