* Denotes required information

* First Name:
* Last Name:
 
* Email Address:

* Confirm:

 
* Date of Birth:
  
 
* I am an
international student:

* I currently reside in
the U.S. or Canada:

 
 
US Military Benefits
I plan to apply for:
 
Ethnic Background:
 
* Address 1:
* Address 1:
Address 2:
Address 2:
* City:
* City:
* State:
State/Province:

Other:
* Zip:
* Postal Code:
* Country:
* Country:
* In what country do you live?
 
Telephone:
example: (000)000-0000
Alternate Telephone:
Telephone:
example: (000)000-0000
Alternate Telephone:
 
* I plan to enroll in:
 
* As a (an):  !

* I am older than 23:

* I will be a:

* I plan to pursue a:

* I am (was)
home schooled:

* I attend(ed) high school in a country outside of the U.S.:

* My last college attended
was outside of the U.S.:


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