Student Information Form

General Information:

Full Name:

Social Security Number (or SIU ID Number):

Gender:   Male     Female

Ethnic Background: African-American    Hispanic      Native American

Date of Birth: 

Marital Status:  Single     Married

                        Spouses Name (if married): 

                        # of Dependents:   

Residency:  Illinois Resident   U.S. Citizen     Permanent Resident

Campus Address:   Street/ PO Box/ Rural Route: 

                                City/ State/ Zip Code: 

                                (Area Code) Telephone #: 

Permanent Address: Street/ PO Box/ Rural Route: 

                                  City/ State/ Zip Code: 

                                  (Area Code) Telephone #: 

Educational Information:  (if applying as a transfer or continuing student)

Applying for:  Fall    Spring     Summer   Year: 

Applying as:  Beginning Freshman    College Transfer    Continuing Student

Current Extracurricular Activities: (School and Community)

Subjects studied and/or studying to date:  (H.S. and transfer students include grades)

Algebra I                   Pre-Calculus         English               

Algebra II                  Calculus                Earth Science     

Plane Geometry          Biology                 Other Science    

Solid Geometry           Chemistry       

Trigonometry               Physics           

Anticipated major: 

High School Information:  Name of H.S.

                                                    Address

                                        Date of Graduation

                                        Rank in Class out of         H.S.  G.P.A. 

College Testing Information:  ACT composite   SAT composite

Community College Information:  Name of College

                                                   Address   

                                                    (Area Code) Telephone #   

                                                    Year in College

                                                    Graduation Date       

                                                    Hours Completed   Hours Enrolled

                                                    Overall G.P.A.

                                                    Do you have an Associate's Degree?  Yes   No

                                                    If Yes, indicate name of school and date degree earned: 

You must sign and date this form before action can be taken. By typing your name in the box below you are signing your signature.

Signature:     Date: