Please review the Eligibility requirements prior to completing

                    Name (Last, First, MI): __________________________________

                    Date: _______________________________________________

                    Date of Birth: _________________________________________

                    SSN: _______________________________________________

                    Home Phone: _________________________________________

                    Home Address: ________________________________________

                    Ethnicity: (circle one or fill in group/tribal name)
                    ___ Native American/ tribe: ___________             _____ Hispanic
                    ___ Pacific Islander                                                _____ African American
                    ___ White/Caucasian                                              _____ Other______________
 

                    US Citizen: _____ Yes         ____ No

                    Class (Junior or Senior): __________________________________

                    E-mail: _______________________________________________

                    Major: _______________________________________________

                    GPA (Overall) ______________

                    Expected Date of Graduation: ______________________________
 

                   a) Write a brief paragraph explaining why you wish to participate in the MARC program

                   b) Submit 3 letters of support from University faculty

                   c) Return application with transcripts