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Student Information

First Name

Last Name

Birthdate

Home Phone (If different than mobile)

Mobile Phone

Student E-mail Address

Parent E-mail Address

Mailing Address

City
RegionCountry
Postal Code

High School/College Information

Name of High School/College Attending/Attended

CEEB Code

Expected Date of Graduation

College Information

Primary Academic Interest/Intended Major

Year Starting at Millersville

Optional Information

Gender

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I identify as Hispanic/Latino

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Millersville University - P.O. Box 1002, Millersville, PA 17551-0302717-871-4636

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