Date____________________
Name _____________ _____________ SS# ___________________ Last First MI
Sex: (circle one) Male Female
Martial Status: (circle one) Single Married Divorced
Minority Status: ____African American ____American Indian ____Hispanic ____Alaskan Native ____Other
Date of Birth: _________________
Home Address: _____________________________________ Street
_____________________________________ City State Zip Code
Email Address: ___________________ Phone: (day) __________________ (evening)________________
High School _________________________ Location _______________________
Date Graduated ______________________ Prospective Major ________________
GSU Classification: (circle one) Freshman Sophomore Junior Senior
Major _____________________
Expected Date of Graduation ___________________________
Are you planning to continue your education in pursuit of a Masters or Doctoral Degree? _______
If yes, in what field of study? __________________________
How did you learn about LAMP? (Posters, high school counselor, peers, newsletters, etc.)
ROTC Affiliation __________________ Military Status ________________
