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Application for Enrollment
Last Name
First Name
Middle Name/Initial
Local Address
Street
Apt. number
City
State
Zip
E-mail
Phone
Permanent Address
Street
Apt. number
City
State
Zip
E-mail
Phone
Purdue Classification
Semester at Purdue
College
Major/Department
Minor
Anticipated graduation date (MM/YYYY)
Personal information
Ethnicity
Age

Citizenship
How did you learn about the DiversiKey certificate program? Selection (can choose multiple items):
Boiler Gold Rush Campus organization
DiversiKey brochure Friend
Academic advisor Exponent
Professor DiversiKey Web site
Other (please indicate)