Semester: Spring

Year: 2005 2006 2007 2008 2009 2010

Name:           E-mail Address:

Maiden Name:

Address:          

City:           State:           Zip Code:          

Social Security Number:

Phone (home): (work):

Have you ever taken a class at LATI previously? Yes No

If yes, what year? Program:

Have you ever applied to LATI? Yes No

COURSE REGISTRATION

DEMOGRAPHIC INFORMATION

The following is regarded as voluntary. The statistical data helps us maintain accurate records and provide accurate demographic information to various funding and government entities.

Gender: Male Female

Ethnic Origin:

Marital Status: Single Married Divorced

Do you have children? Yes No

US Military Veteran: Yes No

Birth date: (M/D/YYYY)

Resident status: US Citizen Yes No

Is English you primary language? Yes No