1. Print Name:

Social Security #:

2. Date of birth:

3. Are you a US citizen / Permanent Resident / Foreign Student? (Circle One)

Permanent Resident US Alien card #: A

4. Foreign Students only: Country of Residence

Legal residency or visa status in the USA / Canada

4. *Telephone: Home

5 a) Current Address:

5 b) Permanent Home Address:

5 c) Email addresses:
(This is a must and all future communication will be through emails)

6. Extra-curricular school activities (attach separate sheet if necessary):