First Name:   Last Name: Middle Initial:

Email Address:

Home Phone:   Mobile Phone:

Birth Date: (mm/dd/yy)

Are you an American Citizen?  Yes   No

Address:   City:

State:   Zip Code:

High School:   Graduation/Planned Graduation Date: (mm/yy)

Are you currently enrolled in college?  YES NO

If NO, what is your high school GPA?

If YES, what college do you attend?

What is your major? Current GPA:

How many hours are you taking? Classification:

What is your expected graduation date from college? (mm/yy)

What is your total SAT score?

Rate your health: excellent good fair poor

Check all that apply:  Prior Service  JROTC

Marital Status: Single Married Widow   Number of Children:

List your hobbies:

List your scholar achievements:

List your athletic achievements:

List your leadership achievements: