SUNY Upstate Microcredential Application

Microcredential Selection

I am

What is your 9-digit Banner Student ID?

What is your Upstate Employee ID #?

Which microcredential are you applying to?

Biographical Information

First Name

Chosen First Name

Middle Name

Last Name

If you have educational records under a different name, give former name(s):

Please enter your mobile number

Email Address

Birthdate

Legal Sex

Gender Designation

Mailing Address

Country

Street

City

Region

Postal Code

Are you a NYS Resident?

Yes

No

Race (Please check all that apply)

Prior Colleges/Degrees

Please list all prior colleges and degrees, starting with your most recently attended school

Please enter your most recently attended school:

Start Date

End Date

Degree Earned

Would you like to add another school?

Yes

No

School # 2

Start Date

End Date

Degree Earned

Would you like to add another school?

Yes

No

School # 3

Start Date

End Date

Degree Earned

Additional Questions

Have you been expelled and/or dismissed from a college for disciplinary reasons?

Yes

No

What were the reasons, from which college and when did it happen? Please provide any additional relevant details.

Have you been dismissed/terminated from a place of employment?

Yes

No

What were the reasons, what was the place of employment and when did it happen? Please provide any additional relevant details.

List any professional credentials you have, including license number(s) and state(s) where you are licensed:

How did you hear about this microcredential?

What lead to your interest in pursuing this microcredential?

Privacy, Conduct, and Compliance

Falsification or omission of this information may result in the denial of admission, the rescinding of your admission or dismissal from the University. Do you verify that the information you have submitted is correct?

Yes

No

The Family Educational and Privacy Act of 1974 (FERPA)
FERPA allows SUNY Upstate Medical University (Upstate) to disclose directory information without prior written consent. Upstate has designated student’s name, mailing address, telephone number, program, class year, Upstate email address, and degrees and honors earned at Upstate as directory information. FERPA allows the student the right to refuse to designate any information as directory information.

Please Indicate:

Yes, allow directory information

No, do not allow directory information

Student Conduct
I have read and positively affirm policies and procedures outlined in the SUNY Upstate Medical University Student Handbook to include: The Student Code of Conduct; University Policies, Drug Free Schools and Communities Act; Personal Safety and Security Information; Guidance on Sexual Harassment and Assault, Bias Crime and Violence Prevention; Violent Felony Investigations and Missing Students; Campus Crime Reporting and Statistics; Upstate Pledge; and the Release of Information and Personal Privacy.
A copy of the current Student Handbook can be obtained at http://www.upstate.edu/currentstudents/

I have read and positively affirm policies and procedures outlined in the SUNY Upstate Medical University Student Handbook

Yes

No

By policy of the State University of New York, all students in attendance at SUNY Upstate Medical University must receive and positively affirm policies and procedures outlined in the SUNY Upstate Medical University Student Handbook. Failure to do so will void your registration at SUNY Upstate and you will not be allowed to attend classes.

Students

Colleges and Programs

Departments, Offices
& Resources

Research at Upstate

Research Administration

Hospitals and Centers

Clinical Services and Resources

Upstate Outreach

About Upstate

Join Upstate

Welcome to SUNY Upstate Medical University

SUNY Upstate Microcredential Application