Date Submitted:

Tue Jan 06 06:43:20 2009

First Name:

Last Name:

Gender

Home Address:

Apt

City:

Zip Code

Home Telephone:

Work Telephone:

Email Address:

Major:

Date of_Birth:

What is your ethnicity? (Check one)

Social Security_Number:

Country of_Birth:

What language do you speak most at home?:

Is this your first semester at this college? (Select one)

During the week, how many hours (if any) do you work?

Were you placed into any Basic Skills course(s)? (select one)

If 'yes', which one(s):

If this is NOT your first semester, what is your current GPA?:

Career goal or interest:

Hobbies/Interest:

Is there anything else you would like to tell us about yourself that would help us to match you with a mentor?:

Please indicate the type of mentor you prefer: Student Faculty/Staff:

Assigned Mentor: