Courses to be enrolled Undergraduate Graduate

Have you ever applied for formal admission to Lock Haven University?   Yes No

Previous College/University Attendance

College/university name and address                        Degree and date earned, if applicable
              

Semester and year for which you are registering        Fall Winter Intersession Spring Summer 1 Summer 2 Summer Extended    Year       

Social Security Number  [will be used as student identifier until LHU student ID number is assigned]
Warning:   You are submitting information over an unsecure site; if you choose not to provide your social security number, you will be contacted for the number by telephone.

Name (last)     (first)     (middle initial) 

Maiden Name (if applicable) 

Street Address 

City       State     Zip 

Telephone Number (including area code) 

Cell/Mobile Phone Number (including area code) 

Date of Birth        January February March April May June July August September October November December          1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 

Business Telephone Number (if applicable) 

Residency Status
County       State       Country 

Local Address (if different from above)

Street or PO Box 

City     State     Zip 

Phone (including area code)  

US Department of Education Questions

What is your ethnicity?  Hispanic or Latino     Not Hispanic or Latino

What is your race?  Mark one or more races to indicate what you consider yourself to be. 
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

Sex  Female Male                            Email Address 

Marital Status (If you choose not to provide this information, please select "not indicated.)  Single Married Divorced Widowed Not indicated

High School Information

Name and address of high school

Date of high school graduation

Course Choices

1st Choice (course # & sec)             
Alternate Choice (course # & sec)     

2nd Choice (course # & sec)             
Alternate Choice (course # & sec)     

3rd Choice (course # & sec)             
Alternate Choice (course # & sec)     

4th Choice (course # & sec)             
Alternate Choice (course # & sec)     

5th Choice (course # & sec)             
Alternate Choice (course # & sec)     

07/31/2009