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* 1. First Name

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* 2. Middle Name or Initial (if applicable)

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* 3. Last Name

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* 4. Street address

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* 5. City

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* 6. State

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* 7. Zip Code

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* 8. Phone Number

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* 9. Email address

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* 10. Are you a High School, Undergraduate, or Graduate student?

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* 11. What year are you currently enrolled in?

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* 12. High School Attended and Date of Graduation

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* 13. Name and Address of College/University (if applicable)

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* 14. Anticipated date of graduation. Please specify high school or college

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* 15. Your Cumulative Grade Point Average

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* 16. Number of credits for which you are presently enrolled (if applicable)

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* 17. Other Information (Name of Faculty Advisor, Address, Phone Number)

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* 18. Please state the name of the firm, beginning and ending dates of your last two employments or internships, and the nature of your assignment at each firm.

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* 19. List of your extracurricular activities in which you participate, any organization to which you belong, or any office held with applicable dates for each.

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* 20. Name of Traffic Club of Chicago Member that you are related to (if applicable)

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* 21. List your relationship to club member listed above (son, daughter, grandson, granddaughter)

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* 22. Are you a current Traffic Club of Chicago Student Member?

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* 23. PERSONAL STATEMENT: Please explain: (1) Why you have chosen your field of study. (2) Your professional objectives following the completion of your degree program. (3) Describe and indicate the amount of any scholarship(s), grant(s), or any other monetary award(s) that you have received this academic year.

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* 24. COPY OF OFFICIAL TRANSCRIPTS: (If transcripts can only be mailed in hard copy, please email staff@traffic-club.org and a mailing address will be provided)

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