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    Personal Data

    First Name

    Middle Name

    Last Name

    Address

    Suite/Apt

    City

    State

    Zip

    How is Permanent Residence Established?

    Home address

    Place of registration to vote

    Family's primary residence

    Other

    Cell Phone

    Home Phone

    Email Address

    Date of Birth

    Citizenship

    Ethnicity

    American Indian or Alaska Native

    A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

    Asian

    A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

    Black or African American

    A person having origins in any of the black racial groups of Africa.

    Caucasian

    A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

    Hispanic or Latino

    A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

    Hawaiian or Other Pacific Islander

    A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

    Gender

    If, Prefer to Self-Describe :

    Preferred Gender Pronoun

    Number of Household

     

    Household Income

    Do You Currently Receive Public Assistance?

    Military Status

    Will You Need Reasonable Accommodations to Participate in this Course?

    Have You Previously Attended College?

    Grade Point Average

    Major

    Number of College Credits Earned to Date

    Select Class Course

    Select Payment

      Full Payment: $3,000.00