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