EXCEL STUDENT APPLICATION 2002

Full Legal Name_________________________________________________
List as : First Middle Last
Permanent Address______________________________________________

City/State/Zip __________________________________________________

Home Phone ________________

Social Security No. __________________Birth Date (mo/day/yr)___/____/___

Ethnic Background
[ ] African-American [ ] Asian [ ] Hispanic [ ] Native American [ ] White Non-Hispanic
[ ] Other _______

Other Language(s) I Speak
[ ] Cambodian [ ] Spanish [ ] Tagalog [ ] Vietnamese [ ] Other _________________

Level of Proficiency (check all that apply)
[ ] Understand [ ] Speak [ ] Translate [ ] Read [ ] Write

Family Information
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List Mother (include maiden name), Father Full Name
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Occupation
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Employer
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Work Phone
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Highest Level of Education

Brothers and Sisters: List Name, Age, Grade Level, School/College

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Language spoken at home_____________________

Schools of Attendance
Middle School_____________________________________________________________________


Elementary School__________________________________________________________________

Courses in Progress
Please list your course schedule for the current academic year. List: Course, Teacher
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Which career(s) are of greatest interest to you?

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Why do you want to join the EXCEL program?

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Please return this completed application as soon as possible to the address below:


Society of Hispanic Professional Engineers
EXCEL Mentoring Program
645 Wool Creek Drive
San Jose, CA 95112