Rollins Certificate Enrollment Form

Please complete the enrollment form below to let us know you'd like to enroll in the Data Analytics with Artificial Intelligence Certificate program. You will need to complete the form in one sitting.

Person Status - Hidden and sets Applicant status

Student Type - Hidden and defaults to Certificate Seeker

Applicant Type - Hidden and defaults to Certificate Seeker

App Round - Hidden field with UG (2025) as default round

App Round Always create (will not try to merge with an existing app) - Hidden and set to Yes

App Submitted Flag - Hidden and set to Yes

App Submitted Date/Time Capture - Hidden

Generate Pin - Hidden and defaults to Yes

Personal Information

First Name

Preferred First Name (if different from above)

Middle Name

Last Name

Birthdate

Contact Information

Email Address

Cell Phone

Can we send you important information and updates by SMS text message to this number?

Yes

No

Address Details

Permanent Address

Country

Street

City

Region

Postal Code

Is your mailing address the same as your permanent address?

Yes

No

Mailing Address

Country

Street

City

Region

Postal Code

Citizenship

Are You a U.S. Citizen?

Yes

No

Are you a Permanent Resident in the U.S.?

Yes

No

If you are not a U.S. citizen or permanent resident, please list your country of primary citizenship.

Country of Birth