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The University of Texas Permian Basin
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Biographical and Demographic Section
Email Address (
Primary contact method
)
First Name
Middle Name
Last Name
Phone Number
Is this a cellphone or a home telephone number
Is this a cellphone or a home telephone number
Home/Landline
Cellphone
May we contact you through your cellphone?
May we contact you through your cellphone?
No
Yes
Social Security Number / National ID
Birthdate
Birthdate
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Mailing Address
Mailing Address
Country
Street
City
Region
Postal Code
Are you a US Citizen
Are you a US Citizen
Yes
No
Which country do you have primary citizenship with?
Afghanistan
Aland Islands
Albania
Algeria
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Ashmore and Cartier Islands
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Bassas Da India
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius, and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Clipperton Island
Cocos Islands (Keeling Islands)
Colombia
Comoros
Congo (Brazzaville)
Congo (Kinshasa)
Cook Islands
Coral Sea Islands
Costa Rica
Cote D'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Europa Island
Falkland Islands (Islas Malvinas)
Faroe Islands
Federated States of Micronesia
Fiji
Finland
Foreign/Unknown
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia, The
Gaza Strip
Georgia
Germany
Ghana
Gibraltar
Glorioso Islands
Greece
Greenland
Grenada
Guadeloupe
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong S.A.R.
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Jan Mayen
Japan
Jersey
Jordan
Juan De Nova Island
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau S.A.R.
Macedonia, Republic of North
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Man, Isle of
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Norway
Oman
Pakistan
Palau, the Pacific Islands of
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Spratly Islands
Sri Lanka
Sudan
Suriname
Svalbard
Svalbard and Jan Mayen
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tromelin Island
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
Gender
Please select one
Female
Male
Prefer not to say
Other
Race
Please select one
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific
White
Decline
What is your gender?
Marital Status
Please select one
Single
Civil Partnership
Common-Law
Companion
Dissolved Civil Partnership
Divorced
Head of Household
Married
Separated
Surviving Civil Partner
Unknown
Prefer not to answer
Widowed
Education History
Have you attended classes at UT Permian Basin before?
Have you attended classes at UT Permian Basin before?
Yes
No
Do you remember your Student ID number?
Do you remember your Student ID number?
Yes
No
What is your student ID number?
Highest level of study, Degree conferred
Please select one
Graduate
High School
Undergraduate
The school that awarded the degree
Occupation and Certification History
Military Service
Are you a current or former military service member, or a family member of one?
Are you a current or former military service member, or a family member of one?
Yes
No
What best describes your military status?
What best describes your military status?
Veteran
Current U.S. military service member
Spouse or dependent
Spouse or dependent of service-connected injury/illness servicemember
Spouse or dependent of deceased servicemember
Veteran and Spouse or dependent
Veteran and Spouse or dependent of service-connected injury/illness servicemember
Veteran and Spouse or dependent of deceased servicemember
Current U.S. military service member and Spouse or dependent
Current U.S. military service member and Spouse or dependent of service-connected injury/illness servicemember
Current U.S. military service member and Spouse or dependent of deceased servicemember
Spouse or dependent and Spouse or dependent of service-connected injury/illness servicemember
Spouse or dependent and Spouse or dependent of deceased servicemember
Spouse or dependent of service-connected injury/illness servicemember and Spouse or dependent of deceased servicemember
Veteran and Current U.S. military service member
Other/Not listed
Please describe your military status
Current Occupation
Current position / title
Company name
Other relevant certifications held
Certification Request
What Academic Semester do you want to start?
Select a semester
Fall 2024
Spring 2025
Fall 2025
Spring 2026
Fall 2026
Students can take individual courses to keep up with continuing education requirements, or they can complete all the required coursework and receive the certification. Which type of student best represents you?
Students can take individual courses to keep up with continuing education requirements, or they can complete all the required coursework and receive the certification. Which type of student best represents you?
Individual Coursework
Complete Certification
Which certificate program are you registering for?
Which certificate program are you registering for?
Diversity, Inclusion, and Health Equity Certificate
Health Informatics & Leadership certificate
Health Informatics and Leadership Certificate Courses
NURS 4344 Informatics and Innovation
NURS 4343 Fiscal and Organizational Leadership
NURS 4342 Quality Improvement and Healthcare Systems
NURS 4341 Healthcare Leadership and Policy
Nursing Credentials (if applicable)
Nursing License Number
Is your license unencumbered?
Is your license unencumbered?
Yes
No
Is your license from a compact state?
Is your license from a compact state?
Yes
No
Which State?
Emergency Contact Information
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Relationship
Relationship
Spouse
Parent
Sibling
Caretaker
Other/Unlisted
What is their relationship to you?
Emergency Contact Phone Number
Submit
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