First Name:

Middle Name:

Last Name:

Suffix:

Nickname: prefer to be called

Gender: Male Female

Date of birth: (use format: mm/dd/yyyy)

I am most comfortable describing myself as: African American Asian Caucasian Latino Native American Other (optional)

Address:

City: State: AK AL AR AZ CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Zip:

Phone:
(Enter your 10-digit phone number using numbers only, beginning with the area code)

E-mail:

Term for which you plan to apply or have been admitted: Spring 2009 Fall 2009 Spring 2010 Fall 2010 (Freshmen can only apply in Fall terms)

Applicant type: Freshman Transfer Readmit

Are you a U.S. citizen or permanent resident? U.S. Citizen Permanent Resident Other

Academic interest #1: Bioengineering Chemical Engineerin Civil ENgineering Computer Engineering Computer Science Electrical Engineering Engineering Management Engineering Physics Industrial Engineering Mechanical Engineering

Academic interest #2: Bioengineering Chemical Engineerin Civil ENgineering Computer Engineering Computer Science Electrical Engineering Engineering Management Engineering Physics Industrial Engineering Mechanical Engineering

Academic Interest #3: Bioengineering Chemical Engineerin Civil ENgineering Computer Engineering Computer Science Electrical Engineering Engineering Management Engineering Physics Industrial Engineering Mechanical Engineering

Total additional guests:

What would you like to attend?

information session

tour

departmental visit

other (please describe)

specialized event (see below)