Prospect Information Form

Please enter the requested information. Please note that an asterisk denotes required information.

Prospect Name
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Nickname:

Prospect Name

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Nickname:

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

Permanent Address

Valid From:

Month Day Year (YYYY)

Until:

Month Day Year (YYYY)

Address Line 1:

Address Line 2:

Address Line 3:

City:

State or Province:

ZIP or Postal Code:

County:

Nation:

Phone Number:

- (xxxxxx)-(xxxxxxxxxxxx) (xxxxxxxxxx extension)

International Access Code:

Your entry term should reflect the year you are graduating from high school or finishing your home school program, or the term you expect to transfer.

Prospect Entry Term
Term of Entry:

Identify Your Student Level
Student Type:

Your Planned Major
Major:

When entering your e-mail address you will need to verify the address by entering it again. If you do not have an email address, you may enter no.email@noemail.com.

E-Mail Address
E-mail Address:
Verify E-mail Address:

E-Mail Address

E-mail Address:

Verify E-mail Address:

Prospect Date of Birth
Date of Birth:	Month Day Year (YYYY)

Prospect Gender
Gender:	Male	Female	Not Specified

Ethnicity is a required field on our application due to federal and state reporting requirements which mandate the data collection.

Prospect Ethnicity/Race
Ethnicity:

What is your ethnicity?

Hispanic or Latino
Not Hispanic or Latino

Select one or more races to indicate what you consider yourself to be.

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

If you were home schooled, enter HOME for the high school code. If you have a GED, enter GED.

Secondary School Information
Home Schooled (check for yes):
OR
High School Code:
High School Name:
Address Line 1:
Address Line 2:
Address Line 3:
City:
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+)

Secondary School Information

Home Schooled (check for yes):

High School Code:

High School Name:

Address Line 1:

Address Line 2:

Address Line 3:

City:

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+)

Prior College Information
College Code:
Prior College Name:
Address Line 1:
Address Line 2:
Address Line 3:
City:
State or Province:
ZIP or Postal Code:
Nation:
Attended From:
Attended To:
Graduation Date:	Month Day Year (YYYY)
GPA:	(example: 9.99)
Degree:

Prior College Information

College Code:

Prior College Name:

Address Line 1:

Address Line 2:

Address Line 3:

City:

State or Province:

ZIP or Postal Code:

Nation:

Attended From:

Attended To:

Graduation Date:

Month Day Year (YYYY)

GPA:

(example: 9.99)

Degree:

ATU

Prospect Information Form

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