Some of the information requested below is provided to the University System of Maryland and other State and Federal agencies as required by law. Data supplied to the USM offices is of a statistical nature only, with no direct reference to you. Please complete this form in full, and submit when complete.

Fields marked by * are required.

* First Name:
* Middle Initial
* Last Name:
* Title (prefix):	Dr. Mr. Mrs. Ms. Prof. Other
* Date of Birth:	(MM/DD/YYYY)
* Address (Number and Street):
* City:
* State:
* Zip:
* County of Residence:
* Home Telephone:
* Email Address:
* Gender:	Male Female
* Marital Status:	Married Divorced Widowed Separated Single/Never Married
* Race:	White Non-Hispanic Black/African American Hispanic Asian or Pacific Islander American Indian or Alaskan Native
* Military Status:	Active Reserve Inactive Reserve Vietnam Era Veteran Other Protected Veteran Retired Military No Military Service
* Highest Level of Education :	Less than High School Graduate High School Diploma or Equivalent Higher Education (specify degree information below
Highest Level Degree Code	-- Select below -- 01-1 year college 02-2 years of college 03-3 years of college 04-4 years of college 06-Dr. of Bus. Admin. 07-Bus. School Cert. 08-Bus. School Work 10-Cert. of Adv. Study 11-Some College 12-Dentistry 13-Divinty/Ministry 14-Dr. of Arts 15-Dr. of Judicial Sci. 16-Dr of Laws 17-Dr. of Musical Arts 18-Dr. of Philosophy 19-Dr. of Sci. 20-Dr. of Social Work 21-Dr. of Program Work 22-Technical school 23-Education 24-2 yr. college degree 25-Bachelor's level degree 26-Grad nurs with Masters 27-Some grad school 28-Masters level degree 29-Doctorate (academic) 30-Doctorate (professional) 31-Post-doctorate 32-Master law 33-Master program work 34-Masters of fine arts 35-Medical specialty work 36-Medicine 37-Optemetry 38-Osteophathy 39-Other Non-Medical Dr. 40-Pharmaceutial Chemistry 41-Podiatry 42-Post Baccalaureate Degree 43-Postdoctoral work 44-RN(less than Bachelor's Degree) 45-RN with Bachelor's 46-Teaching Cert. 47-Trade school work 48-Trade school Cert. 49-Veterinary Sci.
Highest Level Degree Type	(i.e. Bachelor's, Master's, Doctor's)
Highest Level Degree Date
Highest Level Granting Institution
Visa Status (if Non-US Citizen) Visa Code:	-- Select below -- A-1 Foreign Diplomatic Personnel A-2 Dependent of A-1 Visa AR1 Alien Registration AY Asylee B-1 Visitor for Business B-2 Visitor for Tourism C-1 Alien in Transit D-1 Alien Crewman E-1 Treaty Trader E-2 Treaty Investor F-1 Student F-2 Dependent of F-1 G-1 Represent of Intl. Org. G-3 Internal Organization G-4 Dependent of G-3 G-5 Personal Employee of G-1 to G-4 H-3 Trainee H-4 Depdent of H 3 Visa Holder H1A Registered Nurse H1B Temper Worker H2B Skilled or Unskilled Worker I Rep of Foreign Info Media J1 Exhange Visitor (Student) J2 Depdent of J1 K1 Fiance of U.S. Citizen K2 Depdent of K1 Visa Holder L1 Intracompany Transferee L2 Depdent lf L1 M1 Vocational Student M2 Depdent of M1 NAT Nato Personnel 0-1 Person of Extraordinary Ability O-2 Accompanying Personnel O-3 Dep. of O-3 or O-2 P-4 Dep. of P-1 to P-3 PR - Green Card Q - Partic in Internl Cultural Exchange R1 Religious Worker R2 Dep. of R1 RF - Refugee TD - Dependent of TN VWB Waiver for Business VWT - Waiver for Tourism
Emergency Contact Information
* First Name:
* Last Name:
* Telephone: