Please print carefully while completing this form

Last Name:____________________________________________________

First Name:____________________________________________________

Social Security/Banner I.D. Numbers: ______________________________

______________________________

Campus Address: ______________________________________________

______________________________________________

Home Address: ______________________________________________

______________________________________________

Telephone Numbers: ( ) / ( )

Campus Home

Male:_____________ Female:_____________

Ethnicity:

African American:________

Latino/a:________

Asian:_______

Native American:________

Other:________

Major Field of Study:____________________________________________

Cumulative Grade Point Average:__________________________________

Graduation Year:_______________________________________________

The undersigned does hereby give consent for his/her Social Security and Banner I.D. numbers to be used to track his/her academic activity.

Signature:________________________________ Date:________________

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FATTAH GRADUATE OPPORTUNITIES CONFERENCE FOR MINORITIES IN HIGHER EDUCATION

STUDENT QUESTIONNAIRE

In 500 words or less, please type or print legibly, your respond to the following questions:

1. Why do you want to attend the Fattah Graduate Opportunities Conference for minorities in higher education?

2. What do you expect to gain by your attendance at the conference?

Please send the Profile Sheet with Essay responses to the African American Cultural Center. If you have any questions please contact Dr. Carolyn Princes at the AACC at (724)-357-2455.