First Name

Middle Name

Last Name

Street address

City

State

Zip

Phone number

E-mail address

Month and Year of Birth (mm/yyyy)

Gender

Male Female

Program you plan to attend

Sat., January 12, 2013, Student Center Sat., April 6, 2013, Student Center

Admissions category

New Graduate Student Returning Graduate Student Teacher Certification/Endorsement Other

Anticipated enrollment

Winter 2013 Summer 2013 Fall 2013 Winter 2014 Summer 2014 Fall 2014

Academic Program (if known)

Have you previously attended EMU?

Yes No

If yes, when did you last attend EMU?

Have you attended more than four colleges/universities?

Yes No

How did you hear about the open house?

Billboard Postcard EMU Website Radio Friend EMU Alumni High School Teacher Phone Call Other