First Name

Last Name

Street address

City

State

Zip

Phone number

E-mail address

Date of Birth

Gender

Male Female

Program you plan to attend

Wed., June 10, 2009, Student Center Wed., Aug. 5, 2009, Student Center

Admissions category

New Undergrad Returning Undergrad Transfer Grad Student Teacher Certification/Endorsement

Anticipated enrollment

Summer 2009 Fall 2009 Winter 2010 Spring 2010 Summer 2010 Fall 2010

Academic Program (if known)

Have you previously attended EMU?

Yes No

If yes, when did you last attend EMU?

How did you hear about Return to Learn?

Billboard EMU Counselor visited your school High School Counselor Postcard EMU Website Radio Friend EMU Alumni College Fair High School Teacher Phone Call Other