Des Moines University Entrance Interview Questionnaire
This secure form must be completed in its entirety. 
* denotes a required question
Program*
Graduating Year*
Name*
First
Last
Social Security Number*
Birth Date (mm/dd/yyyy)*
  
Driver's License*
Number
State
Permanent Address*
Street
City
State
Zip
Phone number
Address while in school (if known)
Street
City
State
Zip
Phone number
Parent/Guardian Information*
First name
Last name
Street address
City
State
Zip
Phone number
Spouse Information (if applicable)
First nameSpouse's employer
Last nameSpouse's employer street address
Street addressCity
CityState
StateZip
Zip
Phone number
Personal References (each must have a different U.S. address and telephone number.) References are required by the Department of Education.
Personal Reference 1*
First name
Last name
Street address
City
State
Zip
Phone number
Personal Reference 2*
First name
Last name
Street address
City
State
Zip
Phone number
Personal Reference 3*
First name
Last name
Street address
City
State
Zip
Phone number
I acknowledge that I have read and understand my rights and responsibilities as well as the other information provided in the Entrance Interview.
BY SUBMITTING THIS INFORMATION, I CERTIFY I HAVE COMPLETED AND UNDERSTAND THE INFORMATION IN THE ENTRANCE INTERVIEW.
Initials*