2016-2017 Student Application
First Name
Your answer
Last Name
Your answer
Middle Initial
Your answer
Student ID #
Your answer
Home Address
Street Address, City, State, Zip Code
Your answer
Primary phone number
Your answer
Cell phone number
Your answer
Most of your classes are held at which campus?
Your answer
Preferred Email Address
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Birth Date
Your answer
Ethnicity
You currently reside with:
Number of people currently residing in your household:
Your answer
Do you have one of the following?
Are you receiving financial aid?
Are you a First Generation college student in your family?
Education Track:
Program of Study/Major:
Your answer
Employment Status
If part-time, how many hours per week?
Your answer
Do you want a mentor?
If so, why?
Your answer
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