* 1. First Name:

* 2. M.I.

* 3. Last Name:

* 4. UCSC student ID #:

* 5. UCSC E-mail or other E-mail 

* 6. Permanent (Home) Address:

* 7. Current Address:

* 8. Racial or Ethnic Background (Check all that apply):

* 9. Gender:

* 10. Date of Birth:

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* 11. City and State or Country of Birth:

* 12. Are you a US citizen?

* 13. If no, are you a permanent resident?

* 14. last 4 digits of SS #:

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