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Information Request Form

Required - indicates a required field.
Prefix:
First Name: Required
Middle Name:
Last Name: Required
Suffix:
Nickname:

Gender:Required Male Female Not Specified

Ethnicity:

Hispanic or Latino
Not Hispanic or Latino

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian and Other Pacific Islander
White

Citizenship:Required

Date of Birth:Required Month Day Year (YYYY)

E-mail Address:Required
Verify E-mail Address:Required

Note: leave the Valid "Until" field blank unless your address will end on a certain date.

Mailing Address
Valid From: Month Day Year (YYYY)
Until: Month Day Year (YYYY)
Address Line 1:Required
Address Line 2:
Address Line 3:
City:Required
State or Province:
ZIP or Postal Code:
County:
Nation:
Phone Number: - (xxxxxx)-(xxxxxxxxxxxx) (xxxxxxxxxx extension)
International Access Code:

Anticipated Major
Major:Required

Home Schooled (check for yes):
OR
High School Code:
High School Name:Required
Address Line 1:
Address Line 2:
Address Line 3:
City:Required
State or Province:
ZIP or Postal Code:
Nation:
Graduation Date: Month Day Year (YYYY)
Class Rank and Size: / (must be numeric)
GPA: (example: 9.99, or A+)

Student Type:Required

Anticipated Entry Term
Term of Entry:Required

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Release: 8.7.2