*Last Name: *First Name: Middle Initial: Suffix: *Mailing Address: *City: *State: State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Indiana Illinois Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *Zip: Country:
University: University Classification by summer of '07: University Classification High School Senior Freshman Sophomore Junior Senior Graduate
Major: Birthdate: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 Gender: Gender Male Female Ethnicity: Ethnicity Other White Non-Hispanic Black Non-Hospanic Hispanic Asian or Pacific Islander American Indian/ Alaskan Nativa Non-Resident Alien Don't Wish to Respond *Day Phone: Evening Phone: Cell Phone: *E-mail: Alternate E-mail:
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