Evening College Application

General Information
First Name:
Middle Name:
Last Name:
Maiden Name:
Preferred First Name:
  
Date of Birth: mm/dd/yyyy
Place of Birth:
U.S. Citizen:
Permanent U.S. resident: 
 If no to both questions, in what country is your citizenship?
 Visa type?
Social Security Number:
  
Address:
City:
State:
Zip:
  
Home Telephone:
E-mail address:
  
Current Employer:
Position:
Business Telephone:
Employer's Address:
Employer's City:
Employer's State:
Employer's Zip:
  
Degree Information
Preferred degree:
I am applying as a:
  
Academic Information
High School:
 City:
 State:
 Dates Attended:
 Year Graduated/ Credits Earned:
   
College:
 City:
 State:
 Dates Attended:
 Year Graduated/ Credits Earned:
  
Trade School/Other:
 City:
 State:
 Dates Attended:
 Year Graduated/ Credits Earned:
  
Statistical Information
Provision of the following information is voluntary. Your confidential response is used for statistical reporting only and does not affect your eligibility for admission.
Ethnic Background:
Religious Preference:
Sex:
Marital Status:
Are you a veteran?
  
Do you have any relatives who are attending / have attended LaGrange College? If so, please list their name and relationship.