PERSONAL INFORMATION Name: 1. Last Name First Name Middle Name Gender: 2. _____ Female _____ Male _____ Decline to State Marital Status: 3. _____ Single _____ Married ______ Divorced/Separated _____ Decline to State Ethnicity: 4a. (Please check all that apply.) _____ _____ Cambodian _____ Caribbean _____ White Black/African descent _____ Chinese _____ Cuban _____ East Indian _____ Filipino _____ Guatemalan _____ Japanese _____ Korean _____ Laotian _____ Mexican _____ Native Alaskan _____ Native American _____ Native Hawaiian ______ Samoan _____ Puerto Rican _____ Salvadoran _____ South American _____ Vietnamese _____ Thai _____ Other _____ Decline to State 4b. Answer if you checked on 4a., if not, skip to question 5. “other” Please describe you ethnic origin, be as specific as possible 5. Contact Information Home Phone Cell Phone Email Address B. ACADEMIC INFORMATION Classification for Fall 2017 (mark one): _____ Freshman _____ Sophomore _____ Junior _____ Senior _____ Graduate (Expected or Received) Date of Graduation ___________ (month) _____________ (year) I am classified as a: _____ Full-time Student _____ Part-time Student _________hours
PERSONAL INFORMATION 1. Name: Last Name First Name Middle Name 2. Gender: _____ Female _____ Male _____ Decline to State 3. Marital Status: _____ Single _____ Married ______ Divorced/Separated _____ Decline to State 4a. Ethnicity: (Please check all that apply.) _____ Black/African descent _____ Cambodian _____ Caribbean _____ White _____ Chinese _____ Cuban _____ East Indian _____ Filipino _____ Guatemalan _____ Japanese _____ Korean _____ Laotian _____ Mexican _____ Native Alaskan _____ Native American _____ Native Hawaiian ______ Samoan _____ Puerto Rican _____ Salvadoran _____ South American _____ Vietnamese _____ Thai _____ Other _____ Decline to State 4b. Answer if you checked “other” on 4a., if not, skip to question 5. Please describe you ethnic origin, be as specific as possible 5. Contact Information Home Phone Cell Phone Email Address B. ACADEMIC INFORMATION Classification for Fall 2017 (mark one): _____ Freshman _____ Sophomore _____ Junior _____ Senior _____ Graduate (Expected or Received) Date of Graduation ___________ (month) _____________ (year) I am classified as a: _____ Full-time Student _____ Part-time Student _________hours