Step 1. Individual Data

Step 1. Individual Data
	* - denotes a required field
	First Name:*
	Last Name:*
	M.I.:
	Social Security Number:*	- -
	Sex:*	Male Female
	Date of Birth:*	Month: Day: Year:

	E-mail:*

	Address
	Street:*
	Apt#:
	City:*
	State:*
	Zip code:*
	Home phone:*	( ) -
	Business phone:	( ) - ext.
	Cellular/Beeper phone:	( ) -
	Are you a New York Resident?*	Yes No
	Are you a U.S. Citizen?*	Yes No
	If not a U.S. citizen, what is your country of citizenship?
	Check your status:	Permanent Resident Refugee/Parolee or Conditional Entrant Temporary U.S. Visa
	Type of Visa:	International Student Other (explain): Expiration Date:
		* - denotes a required field