First Name        Middle Initial           Last Name

Permanent Address

City      State      Zip Code 

Phone Number             E-Mail Address

Sex   M    F                   Date of Birth (MM/DD/YYYY)    

Name of Parent or Guardian

High School Attended

Graduation Date (MM/YYYY)

If you did not complete High School, indicate date & place GED was completed:

Date      Place

Post-Secondary School which applicant will attend or is currently attending

Name of Institute

Address 

City      State   Zip 

Year in post-secondary during coming school year:  Undergraduate   1  2  3  4  5

Student will:   Live on Campus   Live off campus    Commute

Student will be enrolled:   Half time or more  Full time

Anticipated date of graduation from post-secondary program: 

Major field of study applicant plans to pursue: