First Name:______________________________________

Last Name:______________________________________

Street Address:___________________________________________________________

City:____________________________ State:________________ Zipcode:___________

Your E-Mail Address:_______________________________________________________

Birth Date (MM/DD/YY):___________ 

Telephone Number (XXX-XXX-XXXX):_____________________________

Are you currently in school:  Yes  No

Name of the school you most recently attended:_________________________________

Graduation Date (MM/DD/YY):___________

Circle the last grade of school you attended:

High School     9     10     11    12

College      1     2     3     4

Do you have any prior military service:    Yes   No

If yes to prior military service, indicate which service, the number of years served, and the 
type of discharged received._________________________________________________

Social Security Number (XXX-XX-XXXX):________________________________________

Name, city and state of up to three colleges you may attend:

College of Choice #1:_______________________________________________________

College of Choice #2:_______________________________________________________

College of Choice #3:_______________________________________________________