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Black Male College Explorers Program Application
Questions marked by * are required.
1. Name: *
2. Email: *
3. Home Address:
4. City/State/Zip:
5. Home Phone:
6. Social Security Number (last 4 digits):
7. Date of Birth (mm/dd/yyyy): *
8. Age:
9. Sex:
  • Female
  • Male
10. Ethnic Background:
11. Person to Contact in Case of Emergency: *
12. Relation to Student: *
13. Emergency Contact Phone: *
14. Emergency Contact Address:
15. Emergency Contact City/State/Zip:
16. Emergency Contact E-mail: *
17. Check area(s) of interest:
  • Business
  • Natural Science
  • Social Science
  • Mathematics
  • Education
  • Art
  • Aviation
  • Music
  • Computer Science
  • Journalism
18. Other profession of interest:
19. List the organizations to which you belong and the honors you have received:
20. Special Skills/Hobbies:
21. Please list current courses: *
22. Current Classification: *
23. Cumulative G.P.A.:
24. Test Scores:
25. Discipline Referrals:
26. Absentees:
27. Tardiness:
28. Suspensions:
29. Incarceration Record:
30. Current Class Schedule:
31. Expected Date of Graduation (month and year):
32. List work or volunteer experiences relevant to your professional interests:
33. Work or Volunteer Position(s):
34. Duties/Responsibilities:
35. Work or Volunteer Date(s):