Optional Information Citizenship / Visa Notice Will you need assistance with a non-immigrant visa? Yes No ☐ ☐ If yes, country of citizenship Birthplace (Country, city, and state or province) If currently in United States, type of visa you now hold Demographic Information (check all that apply) Hispanic Native Hawaiian or American Indian / ☐ ☐ ☐ ☐ US Pacific Islander Alaskan Native Central American Cambodian Hawaiian African American ☐ ☐ ☐ ☐ Chinese Guamanian or American Born African ☐ ☐ ☐ ☐ Mexican, Filipino Chamorro African ☐ ☐ ☐ Chicano / Indian Samoan Caribbean Black ☐ ☐ ☐ Chicana Japanese US Pacific Other black, specify ☐ ☐ ☐ Puerto Rican Korean Islander, specify ☐ ☐ South American Laotian ☐ ☐ Other Spanish Pakistani ☐ ☐ culture or origin Taiwanese ☐ regardless of race Thai ☐ (except Spain) Vietnamese ☐ Other Asian, specify ☐ Non-Hispanic American Indian / White Female ☐ ☐ ☐ ☐ Alaskan Native Male ☐ Specify Tribe/ Community:
Optional Information Citizenship / Visa Notice Will you need assistance with a non-immigrant visa? ☐ Yes ☐ No If yes, country of citizenship Birthplace (Country, city, and state or province) If currently in United States, type of visa you now hold Demographic Information (check all that apply) ☐ Hispanic ☐ ☐ Native Hawaiian or US Pacific Islander ☐ American Indian / Alaskan Native ☐ Central American ☐ ☐ Mexican, Chicano / Chicana ☐ Puerto Rican ☐ South American ☐ Other Spanish culture or origin regardless of race (except Spain) ☐ Cambodian ☐ Chinese ☐ Filipino ☐ Indian ☐ Japanese ☐ Korean ☐ Laotian ☐ Pakistani ☐ Taiwanese ☐ Thai ☐ Vietnamese ☐ Other Asian, specify ☐ Hawaiian ☐ Guamanian or Chamorro ☐ Samoan ☐ US Pacific Islander, specify ☐ African American ☐ American Born African ☐ African ☐ Caribbean Black ☐ Other black, specify ☐ Non-Hispanic ☐ American Indian / Alaskan Native ☐ White ☐ Female Specify Tribe/ Community: ☐ Male