Name:

* First Name:

*Last Name:

Phone/Email:

*Home Phone:

Work Phone: Fax:

*Email:

Mailing Address:

*Address 1:

Address 2:

*City:

*State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau *Zip/Postal:

Country:

*Birthdate: (YYYY/MM/DD)

Sex: None Male Female

Race/Ethnic Background: None American Indian or Alaskan Native Asian or Pacific Islander Black, non-hispanic Hispanic Other

Educational Background:

*H.S. Diploma GED

*Name of High School or enter GED:

*Year of High School graduation or GED:

*Please list all colleges/universities you have attended (if none, enter NONE):

1.

2.

3.

4.

5.

Please indicate the level of education you have attained:
Some college credits
Certificate
Associate's degree
Bachelor's degree
Masters degree or higher

*What is your major of interest?: Select Major Accounting Agriculture Allied Medical Prof. Architecture Arts and Sciences Business Dentistry Dental Hygiene Early Childhood Education Economics Elementary Education (pre-certification) Education-other Masters of Education (certification) Engineering Human Ecology Master of Arts (El. Ed 1-8) Medicine Music Natural Resources Nursing Nursing-Project Learn BSN Optometry Pharmacy Psychology Social Work Master of Social Work Veterinary Medicine Continuing Education Credit Programs Undecided Other-enter in space provided

Other

*Please indicate the quarter and year you intend to start college:

QuarterAutumn (September)Winter (January) Spring (March) Summer (June)

Year 2009 2010 2011 2012

Are you interested our Post-Secondary Enrollment Option Program: 
OSU Academy?

None yes no