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Please provide as much information as possible as it helps us maintain accurate records.

- indicates a required field.
Please type in your name using a mixture of upper and lower case letters as you would want it to appear on official documentation. (Example: First Name=John; Middle Name=Allen; Last Name=MacMillan).

Suffix is an optional field.
You may leave the Suffix field blank, but if a suffix is part of your legal name, enter one of the following valid suffixes: I, II, III, IV, V, VI, VII, Jr, Sr.

Prospect Name
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Nickname:

Prospect Birthdate
Date of Birth: Month Day Year (YYYY)

E-Mail Address
E-mail Address:
Verify E-mail Address:

Additional Telephone Numbers
Telephone Type:
Phone Number: - (xxxxxx)-(xxxxxxxxxxxx) (xxxxxxxxxx extension)
International Access Code:
Telephone Type:
Phone Number: - (xxxxxx)-(xxxxxxxxxxxx) (xxxxxxxxxx extension)
International Access Code:
Telephone Type:
Phone Number: - (xxxxxx)-(xxxxxxxxxxxx) (xxxxxxxxxx extension)
International Access Code:

Please indicate the semester in which you intend to enter the University.

Prospect Entry Term
Term of Entry:

Please provide your complete mailing address. This should be the address where you are most reliably reached by mail. For Address Line 1, please enter street address or PO Box using complete words (no abbreviations) and upper and lower case letters (Example: 123 South Monroe Street). For Address Line 2, please enter apartment number and/or additional street address information (Example: Apartment 1A). Use the drop down menus for State, County (Illinois only) and Nation.

Enter your phone number in the following format:
Box 1=area code; Box 2=7-digit phone number; Box 3=extension (if applicable)
Example:
217 5556600 ext

Primary Address
Valid From: Month Day Year (YYYY)
Until: Month Day Year (YYYY)
Address Line 1:
Address Line 2:
Address Line 3:
City:
State or Province:
ZIP or Postal Code:
County:
Nation:
Phone Number: - (xxxxxx)-(xxxxxxxxxxxx) (xxxxxxxxxx extension)
International Access Code:

Please indicate your gender below.

Prospect Gender
Gender: Male Female Not Specified

Please select your intended major or field of study from the pull-down menu.

Prospect Major
Major:

Please indicate your ethnicity and race below.

Ethnic Identification and Racial Identification Note: Your response to these items is voluntary. Please enter the ethnic and racial identification information to help the University meet its federal reporting obligations. Additional information about these regulations is available in the Race and Ethnicity section of the University of Illinois web site.

First, identify whether or not your ethnicity is Hispanic or Latino, regardless of race. Second, select one or more races from the five racial groups. Hold down the Control key in order to select more than one racial group.

Prospect Ethnicity/Race
Ethnicity:

Ethnic Identification (select one):

Hispanic or Latino
Not Hispanic or Latino

Racial Identification (select one or more groups):

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
American Indian or Alaska Nati
Asian
Black or African American
Native Hawaiian or Other Pacif
White

Please indicate the name of the college or university you are attending or attended, if applicable. If you have attended more than one institution, please indicate the one attended most recently. Click on Look Up College Code to search for your prior college. The previous college list contains both US and international institutions. If you cannot find your institution listed, enter as much information as you can. Enter the GPA on a 4.0 scale. If you are not sure of the day of your graduation, use the first day of the appropriate month (Example: June 01 2004.) Enter the degree you have received or expect to receive.

Prospect Prior College
College Code:
Prior College Name:
Address Line 1:
Address Line 2:
Address Line 3:
City:
State or Province:
ZIP or Postal Code:
Nation:
Attended From:
Attended To:
Graduation Date: Month Day Year (YYYY)
GPA: (example: 9.99)
Degree:

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Release: 8.7.2.12