Personal Information

Full Legal Name

First name (given name)

Middle name (if applicable)

Last name (family or surname)

Permanent Address

Street address

City

State or Province

Zip/Postal code

Country

Postal Code

Contact Information

Daytime phone

Mobile phone

Email address

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Academic Information

Student type

Anticipated start term

Anticipated start year

Current (or most recently attended) school

Academic area(s) of interest

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Demographic Information

Date of birth

mm/dd/yyyy

Gender

femalemaleother

Check all that characterize your race.

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Active duty

yesno

Veteran

yesno

ROTC Interest

yesno