Department of Computer Science
5-Year BS-MCS Degree Program Provisional Application
1210 Siebel Center, MC-258 • 201 North Goodwin • Urbana IL, 61801
Application deadline for Fall term is March 15th.
Please return completed applications to the Academic Office at 1210 SC.
Demographics and Contact Information
Last Name:____________________________________
First Name:____________________________________
Middle:_______________________________________
Previous:______________________________________
Email Address: _________________________________
Net ID: _______________________________________
UIN #:________________________________________
Gender: ___Male ___Female
Race/Ethnicity: _________________________________
Date of Birth: ____ Month ____ Date _____ Year
Birth City:_____________________________________
Birth State: ____________________________________
Birth Country: __________________________________
Permanent Address
Street: _______________________________________
City:_________________________________________
County:_______________________________________
State:________________________
Province: _____________________Zip: ____________
Country:______________________________________
Phone Number: (____) __________________________
Current Address
Street: _______________________________________
City:_________________________________________
County:_______________________________________
State:________________________
Province: _____________________Zip: ____________
Country:______________________________________
Phone Number: (____) __________________________
Citizenship and U.S. Residency
Country of Citizenship: _____________________________
Citizenship Type: __Domestic __International
Permanent U.S. Resident Alien/Immigrant: __Yes __No
Alien Registration Receipt Card #: ____________________
International Applicants
Country of Legal Permanent Residence: ________________
Current Type of Visa: _______________________________
Visa Expiration Date: _______________________________
Visa Number: _____________________________________
Current Program Sponsor: ___________________________
Date I-94 Expires: _________________________________
Do you need visa eligibility documents from U of Illinois? __Yes
__ No Indicate Type: ________________________ Program
Sponsor: _________________________________
If no, indicate Program Sponsor who will issue them:
________________________________________________
Illinois Residency
Will you have lived in Illinois (for non-educational purposes) for 12
months preceding the term you are applying for: __Yes __No
Has at least one of your parents maintain a permanent residence in
Illinois for one or more years? __Yes __No
Parent First Name: _____________________________
Parent Last Name: _____________________________
Will at least one parent(s) lived in Illinois for 12 months preceding
the term for which you are applying? __Yes __No
University of Illinois Education Information
st
Current Standing in CS Major: __1 Sem. Jr. __2nd Sem. Jr.
Term Your BS Component will be complete (includes satisfying the 120 hrs + 3 grad distribution courses): _____________________
List any Scholarship, Honors & Internships: ___ _________________________________________________
______
________________________________________________
________________________________________________
______________________________________________
__
Honor Societies & Professional Organizations: ______
______________________________________
________________
____
__________
________________________________
August 2013 v2
Department of Computer Science
5-Year BS-MCS Degree Program Provisional Application
1210 Siebel Center, MC-258 • 201 North Goodwin • Urbana IL, 61801
Application deadline for Fall term is March 15th.
Please return completed applications to the Academic Office at 1210 SC.
Post Secondary Education: Please indicate all of the universities and colleges you have attended including the
University of Illinois, listing the most recent institution first. If you have attended more than three institutions,
please submit additional pages. An official transcript must be submitted to the department for each institution
unless you have already submitted those transcripts to the Office of Admissions and Records.
Institution
(Name, City, State, Country)
Major
Minor
Dates
Attended
(From-To)
Diploma, certificate, or degree
awarded in original language
and exact English Translation
Date
awarded or
expected
GPA / Rank /
Degree Class
(if applicable)
Experience: Professional, internships, business, military, etc. Account for all your time since you began your
undergraduate work to the present.
References: Include at least three letters of reference to support your application. Each should be well acquainted
with your character and intellectual abilities. Provide the full name and address of all references below.
Name:
Address:
City:
State:
Zip:
Email:
State:
Zip:
Email:
State:
Zip:
Email:
Name:
Address:
City:
Name:
Address:
City:
Statement of Purpose: Please attach your 1-2 page “Statement of Purpose” to this application. Remember to
include your name, Net ID, UIN, and date of birth on each page.
Agreement: Please read this statement and sign below. “I understand this is a provisional application to the 5year BS-MCS Degree Program in Computer Science. I have read the 5-year BS-MCS Degree Program description
and understand the requirements to earn the combined degree.
Name:
Date:
August 2013 v2