Undergraduate Application - Galen University

*Three (3) references must be provided*

Principal/Vice Principal	Teacher	Community Leader
Name: Position: Contact:	Name: Position: Contact:	Name: Position: Contact:

Semester of intended entry:	Year:	Campus:
Are you applying to be a Full-time or Part-time student? full-timepart-time
Academic Degree Programs:

Concentration:	Diploma:
Have you previously applied to or attended Galen University? NoYes
If yes, when did you last apply and/ or enroll?
Year applied:	Last semester/year enrolled:	Student ID #:

**Legal Name (Please enter your name as it appears on your passport and/or other official documents.)

Last:	First:
Middle:	Suffix: (Jr., Sr., if applicable)
Previous last name:	Birthdate:
Identification Document: Social Security NumberPassport Number	Document #:
What best describes your gender?: MaleFemaleTransgenderNon-ConformingPrefer not to Say

Nationality:	Place of Birth:
Street Address:	City/Town/Village:	District:

Street Address:	City/Town/Village:
District:	E-mail Address:
How many phone numbers do you have?: 123

Phone 1:

Phone 2:

Phone 1:

Phone 2:

Phone 3:

Do you have any learning disabilities? If yes, kindly share:
Do you have any medical conditions that may create an emergency on campus or on a University trip (e.g. allergies, diseases, etc.)? If yes, kindly share:
Blood Type:
Emergency Contact Name:	Relation:
Emergency Contact email:	Emergency Contact Cell #:

Secondary School completed:
Year Graduated:	Cumulative GPA:
Tertiary School Attended: (if applicable)	Country: (if applicable)
Year Graduated: (if applicable)	Degree earned: (if applicable)
Major:	Cumulative GPA:

Please, be sure to prepare your application package before start filling the form. It should include:

One (1) official High School transcript
One (1) copy of high school diploma (can be submitted after application package)
One (1) copy of any of the following test scores – ATLIB, CXC, ACT, SAT (if available)

(Please compile all your docs in one file and compress/zip before uploading)

Please indicate the source(s) and reason(s)that led you to apply to Galen University:

Sources: High School Counselor/TeacherFriends/FamilyGalen University student or graduateWebsiteEducation FairThe Galen HourSocial MediaRadio AdTV AdBillboardAdvertisementOther
Reasons: ReputationPossibilities to transfer to USA/UKQualifications to be attainedReasonable tuition and feesSafety/SecurityOther