M Number.: ________________________    Date of Application:_________________________

Name:____________________________________________________________________________
                    (Last)                                                (First)                                (Middle)

Permanent Address:__________________________________________________________________
                                   (Street)                                            (City)                    (State)                (Zip)

Current Address:____________________________________________________________________
                                     (Street)                                            (City)                    (State)                (Zip)

Permanent Phone(_____)______________________Current Phone:(______)_____________________

E-mail Address:______________________________Cell Phone:_______________________________

Classification:____Freshman____Sophomore____Junior____Senior____Grad. Student____Irregular

Area/Major:_______________________Major 2:___________________Minor:___________________

Academic Advisor:__________________________Department:_______________________________

Degree Pursuing:____________________________Degree Completed:__________________________

Overall GPA:__________Major GPA:____________Date of Graduation:________________________

Teacher Certification:_________________________Qualified to Coach:_________________________

The following information is not required but helpful in completing statistical information only by the Career Services office.

Gender:____________Ethnic Background:______________________Birthdate:__________________

Are you a U.S. Citizen?_____Yes______No   Are you a veteran?_______Yes_______No

It is the responsibility of the student to inform the Career Services office or an employer of any special assistance needed to perform a job due to a disability.

Student Signature:__________________________________________________________________