Southern Oregon University Self Service

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Prospect Information Form

Please enter the requested information. Please note that an asterisk denotes required information. COUNTY is only applicable for Oregon residents. In INTERESTS, to select multiple values use Ctrl+Click for PC and Command+Click for Mac.

- indicates a required field.

Name
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Nickname:

Mailing Address
Valid From:	Month Day Year (YYYY)
Until:	Month Day Year (YYYY)
Address Line 1:
Address Line 2:
Address Line 3:
City:
State or Province:
ZIP or Postal Code:
County:
Nation:
Phone Number:	- (xxxxxx)-(xxxxxxxxxxxx) (xxxxxxxxxx extension)
International Access Code:

Birthdate
Date of Birth:	Month Day Year (YYYY)

Citizenship
Citizenship:

E-Mail Address
E-mail Address:
Verify E-mail Address:

Term You Want to Start at SOU
Term of Entry:

Ethnicity/Race
Ethnicity:

What is your ethnicity?

HispanicNot Hispanic

Hispanic or Latino
Not Hispanic or Latino

Hispanic or Latino

Not Hispanic or Latino

Select one or more races to indicate what you consider yourself to be.

American Indian or Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White
Alaskan Native American Indian American Indian - Other American Indian - Paiute (Burns OR) American Indian - The Klamath Tribes Cherokee Coquille Indian Tribe Cow Creek Band of Umpqua Indians Grand Ronde Navajo Nez Perce Piute Siletz Sioux Tribes of Coos, Lower Umpqua and Siuslaw Umatilla Wasco/Warm Springs Yakama	Asian Asian - Other Asian Indian Cambodian (Kampuchean) Chinese Filipino Hmong Indonesian Japanese Korean Laotian Mienh Pakistani Thai Vietnamese	Black or African American	Fijian Guamanian Hawaiian Melanesian Micronesian Pacific Islander Pacific Islander - Other Polynesian Samoan Tongan	Algerian Armenian Azerbaijani Baluchi Bedouin Berbers Copts Druze Egyptian Hazara Iranian Iraqi Israeli Jordanian Kurd Lebanese Libyan Maronite Middle Eastern Middle Eastern - Other Moroccan North African North African - Other Nubian Palestinian Pushtun Qashqa'i Saudi Somalis Sudanese Syrian Tunisia Turks White Yazidis Yemenis

Gender
Gender:	Male	Female	Not Specified

To select multiple values use Ctrl+Click for PC and Command+Click for Mac.

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Southern Oregon University Self Service

Prospect Information Form