Data Collection Form-Prep

Term

Last Name, First & Middle Name

Banner ID

Home Address:

Minnesota County of residence (if you are a resident of MN)

Citizenship

	USA citizen
	Other

Country of Citizenship if you checked OTHER above

Phone numbers:

	Home phone
	Cell Phone:

Email Address:

Gender

Date of Birth (MMDDYYYY)

Ethnic (we are required to request this information by Federal Statute)

	White Non Hispanic
	Non-Resident Alien (non US Citizen)
	Asian
	American Indian or Alaskan Native
	Black Non-Hispanic
	Hispanic
	Native Hawaiian/Pacific Islander
	Two or More Races

Have you ever taken any classes through the university, include SJU college prep courses

Yes No

If yes, time of last Attendance (term & year)

Courses Requests

Student signature

Student signature date