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Location: (ex.: Lafayette)
Term: (ex.: Fall)
Year: (ex. 2003)
Full Name (including middle initial):
Student ID:
Address:
City, State, Zip:
Has your address changed in the last 12 months? Yes No
Email Address:
Home Phone:
Work Phone:
Employer*:
* Employer Information is confidential and will only be used for statistical purposes.
Are you a candidate for graduation this semester? Yes No

CLASSES TO BE TAKEN:
	Dept.	Course	CRN	Title	Day or Night
example=>	OLS	252Y	34489	Human Behavior in Organizations	Night








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Lafayette
5500 State Road 38E, AD 2900
Lafayette, IN 47903

Phone: (765) 269-9630
Email: techlafayette@purdue.edu

College of Technology
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West Lafayette, IN 47907

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