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Name/Address

Prefix:

First Name:

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Middle Initial:

Last Name:

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Date of Birth:

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Gender:

Male

Female

Address 1:

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Address 2:

City:

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State/Province:

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Zip Code:

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Country:

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Home Phone:

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Work Phone:

E-mail Address:

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Active military or veteran?:

Yes, I am active military or veteran

Requested Information

Term:

Year:

Program:

How did you hear about UC?:

Major 1:

Major 2:

Comments:

Advisor Contact

Have an Advisor Contact Me:

Yes, I'd like to have an advisor contact me

Please Contact Me Via:

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Phone

E-mail

Best Day and Time to Contact me is:

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Best Phone Number to Call is:

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