First Name

Last Name

Street address

City

State/Province

Country

Zip

Phone number

E-mail address

Date of Birth (mm/dd/yyyy)

Gender

Male Female

Admissions category

Freshman Transfer Graduate student International

Anticipated enrollment

Fall 2012 Winter 2013 Summer 2013 Fall 2013 Winter 2014 Summer 2014 Fall 2014 Winter 2015 Summer 2015 Fall 2015

Intended Major

School Currently Attending

Parent email address (freshman only)

Who/what caused you to request information?

Billboard EMU Counselor visited your area High School Teacher/Counselor Postcard EMU Website Radio Friend EMU Alumni Message from cappex.com Message from zinch.com Phone Call Other

Additional Comments/Questions/Requests