Information Request Form Galveston - Graduate
* Indicates a required field or an issue in the form.
Please complete using your full legal name as it appears on your birth certificate or passport.
First/Given Name:* Last/Family Name:*
Middle Name:

Address Line 1:* Address Line 2:
City:* State:
Zip: Nation:*
Phone Number: -
Format of Domestic Numbers: "Example: 979-5555555"

International Numbers: Enter your country code and international access code in the first space provided
and your phone number with no hyphens in the second. Example: "01144-8735555555"

Verify E-mail:*

Date of Birth:*
Year (YYYY)

Gender: Male    Female

Term of Entry:* Major:

Ethnicity: Hispanic or Latino Not Hispanic or Latino

Race: Please select the racial category or categories with which you most closely identify. Check as many as apply.

American Indian / Alaskan Native
Native Hawaiian or Other Pacific Islander

College Code:
Graduation Year: (YYYY)