Permanent Address:    Street/ PO Box 

                                      City  State     Zip code

                                      Permanent phone#

Current/Local Address:  Street/ PO Box
                                                                    (please indicate if SHSU box)

                                        City  State     Zip code

                                        Current/local phone# 

                                        E-mail address 

Education Information:
University/College Attending?  University/College Classification--select one--FreshmanSophomoreJuniorSenior Graduate Student Alumnus/a

 Major     Minor 

Comments or additional informaion.