Undergraduate Reactivation Form

*Required Fields

Student I.D. (If Known): 9 Digits on Your All Card, including 000

Social Security Number (Do not Include Dashes)

*For Social Security Number, if you are an international student please enter 000000000.

First Name

Last Name

Middle Name

Previous Last Name

Email Address

Birthdate

Requesting reactivation for the following term

Reason for leaving Xavier

Program declared when last enrolled at Xavier

If Other, what program?

Would you like to stay as this program?

Yes

No

What program are you intending on changing to if you are reactivated?

Have you attended other colleges or universities since leaving Xavier?

Yes

No

Name of College/University Attended since leaving Xavier

Internal field: College/Univ Key

Internal field: Level of Study IN College

**If yes, send official transcript to: Xavier University, c/o Office of the Registrar, 3800 Victory Pky., Cincinnati OH 45207-3351
NOTE: All future registration will be restricted until transcripts are received.

Permanent Information

Permanent Address

Country

Street

City

Region

Postal Code

Permanent Phone

Local/Temporary Information

Local Address

Same as Permanent Address

Country

Street

City

Region

Postal Code

Local Phone