Information Request Form

Student's Last Name:	First Name:		MI:
Mailing Address:		Physical Address:
City/State/Zip:	E-Mail Address:
Phone Number:	Second Phone Number:
Is the student a US Citizen or Permanent Resident? Yes No
Student's Academic plans after high school?
How did you hear about the UB program?
Does any of the student's parents/guardians have a Bachelors degree? yes no
What grade is the student in now?	What school does the student attend?
What kind of grades does the student usually receive?	I am a: If you are not a student please enter your Name/Title:
What kind of information are you requesting?
Questions or comments