Email Address: ________________________________________ Phone:_________________
Mailing Address: ______________________________________________________________
City: ____________________________ State: ________________ Zip Code:_____________
Humboldt County Residency Since:____________________
School/Institution:____________________________________________________________
Major:______________________________________________________________________
Eligibility Status (circle one): Student Recent Graduate
For Current Students: Unit Load: Fall 2008 _____ Winter 2009 _____ Spring 2009 _____
For Recent Graduates: Graduation Date______________________
Signature: ________ Date: _________________