PERSONAL INFORMATION

Last Name: First Name:

Banner ID #: Birth Date (MM/DD/YY): Age:

Local Address:

City: State: Zip Code:

Local Phone Number: Permanent Phone Number:

E-mail Address:

Parent or Guardian's Name(s):

Do you plan to be employed this fall? Please Select Yes No If so, how many hours per week?

How long do you plan to be enrolled at YSU? Year(s)

What is your major?

Please select your classification for Fall Semester 2009: Please Select 1st Time Freshman Freshman Sophomore Junior Senior Transfer

ACADEMIC INFORMATION

High School:

City: State: Zip Code:

Date Graduated (MM/DD/YY): High School GPA:

Are you a transfer student? Please Select Yes No Overall College GPA:

Previous college(s) attended?

Please leave blank if you have not attended any previous college(s) other than Youngstown State University.

YSU GPA: Total number of college hours completed:

Activities and Honors (High School and College: List everything)

FRATERNITY INFORMATION

Have you ever been a Pledge of a National Collegiate Fraternity? Please Select Yes No

If so, which chapter? On what campus?

Date Pledged? (MM/DD/YY) Date Terminated? (MM/DD/YY)

Are any relatives members of a fraternity? (Include: Fateher, Brother, Uncle, Grandfather)

Name: Relationship:

Fraternity: Campus:

I hereby release all of the above information, including my grades and judicial information to the Interfraternity Council for recruitment reasons and to Youngstown State University administrators as needed. Discretion will be used in the release of any information. Use of this information will be exclusively in support of the University’s educational mission.

ELECTRONIC SIGNATURE:

I understand that by checking this box that the electronic signature provided above will be used as the same consent that my written signature would.