First Name:

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* 1. First Name:

M.I.

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* 2. M.I.

Last Name:

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* 3. Last Name:

UCSC student ID #:

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* 4. UCSC student ID #:

UCSC E-mail or other E-mail 

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* 5. UCSC E-mail or other E-mail 

Permanent (Home) Address:

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* 6. Permanent (Home) Address:

Current Address:

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* 7. Current Address:

Racial or Ethnic Background (Check all that apply):

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

Gender:

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* 9. Gender:

Date of Birth:

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* 10. Date of Birth:

.
City and State or Country of Birth:

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* 11. City and State or Country of Birth:

Are you a US citizen?

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* 12. Are you a US citizen?

If no, are you a permanent resident?

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

last 4 digits of SS #:

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* 14. last 4 digits of SS #:

T