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 2010 _____ Winter 2011 _____ Spring 2011_____
For Recent Graduates: Graduation Date______________________
Have you been convicted of, or plead no contest to, a misdemeanor or a felony? Yes No
Are you currently involved with any pending legal action? Yes No
If your answer is yes to either, please explain:
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Signature: ________ Date: _________________