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Regardless of your answer to the prior question, please indicate how you identify yourself and describe your background.
(You may select one or more)
American Indian or Alaska Native
Are you enrolled in a federally recognized tribe?
Yes No
If yes, please enter Tribal Enrollment Number
Asian (including Indian subcontinent and Philippines)
Black or African American (including Africa and Caribbean)
Native Hawaiian or other Pacific Islander
White (including Middle East)
Family
Please list both parents below, even if one or more is deceased or no longer has legal responsibilities for you. If you are a minor with a legal
guardian, please include that information. You may list step-parents and/or other adults you live with, or who care for you, in the additional
information section.
Household
With whom do you make your permanent home?
Parent 1 Parent 2 Both parents Legal guardian Ward of the court/state Other
Specify other living situation If you have children, how many?
Parents’ marital status (relative to each other)
Married Separated Divorced Never married Widowed Civil union/domestic partners
Parent 1
Mother Father
Is parent 1 living?
Yes No
Date deceased
mm/yyyy
First/given name
Middle
Last/family/surname Suffix
Former last/family/surname (if any)
Preferred phone
Home Mobile Other Work
Include area/country/city code
Preferred email
Occupation (former, if retired)
Occupation/Employer
College attended (if any)
Degree Year
College attended (if any)
Degree Year
Parent 2
Mother Father I do not have another parent to list
Is parent 2 living?
Yes No
Date deceased
mm/yyyy
First/given name
Middle
Last/family/surname Suffix
Former last/family/surname (if any)
Preferred phone
Home Mobile Other Work
Include area/country/city code
Preferred email
Occupation (former, if retired)
Occupation/Employer
College attended (if any)
Degree Year
College attended (if any)
Degree Year
Legal guardian (if other than parent)
First/given name
Middle Last/family/surname
Suffix
Former last/family/surname (if any) Relationship to you
Preferred phone
Home Mobile Other Work
Include area/country/city code
Preferred email
Occupation (former, if retired)
Occupation/Employer
College attended (if any) Degree
Year
College attended (if any) Degree
Year