Part 1: Your Personal Profile Last Name First Name Middle Initial Address 1 Address 2 City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Telephone Social Security Number Birth Date Birth Place Gender - None -MaleFemale Email Citizenship Are you a US citizen? Yes No Are you a permanent resident of the United States? Yes No Ethnic Background Ethnic Background American Indian or Alaskan Native Hispanic White Asian or Pacific Islander African American / Black Native Hawaiian or other Pacific Islander More than one race What language, if any other than English, is spoken in your home? Are you fluent in that language? Yes No Part 2: Educational Data School Name School Address Current Grade Grade Point Average (GPA) Guidance Counselor or Advisor's Name Test Information:In the following section, enter your scores for the listed exams.If you have not taken a test, leave it blank. GEPA Date Administered Math Score Reading Score Writing Score Science Score Total HSPA Date Administered Math Score Reading Score Writing Score Science Score Total PSAT Date Administered Math Score Reading Score Writing Score Science Score Total SAT Date Administered Math Score Reading Score Writing Score Science Score Total SAT II Date Administered Math Score Reading Score Writing Score Science Score Total Academic Honors List any honors/awards you have received Extracurricular Activities List any extracurricular, community or family activities After High School Do you plan to attend college? Yes No College Major(s) Possible area(s) of concentration / major Career Objectives Possible career or professional plans Work Experience List any job (including SYETP) you have held during the past three years. Part 3 Parent/Family Confidential Information Parents are: Parents are: - None -MarriedDivorcedSingle or Never MarriedWidowedSeparatedOther… Enter other… Father/Male Guardian Name Home address, if different from yours Living? - None -YesNo Mother/Female Guardian Name Home address, if different from yours Living? - None -YesNo If not with both parents, with whom do you make your permanent home? Other children or "dependents" in your family householdPlease include Name, Sex, Age, Relationship , School or College Attending 1 2 3 4 Total number of people in household (including applicant) Is the applicant a foster child? - None -YesNo A foster child is considered a "family of one" and the child's support payment is considered that family's income. Family Income InformationInclude only persons living in household Father / Male Guardian / Head of household employed? - None -YesNo Mother / Female Guardian / Head of household employed?' - None -YesNo Source of income - None -EmploymentWelfareSocial SecurityV.A. BenefitsUnemployment Total family income $ per year