First Name *

Middle Name

Last Name *

Email

Phone

Address 1

Address 2

City

State/Province
- Select State Alabama Alaska American Samoa Arizona Arkansas Armed Forces Afr/Can/EU/ME Armed Forces Americas Armed Forces Pacific Baker Island California Colorado Connecticut Delaware Federated State of Micronesia Florida Georgia Guam Hawaii Howland Island Idaho Illinois Indiana Iowa Johnston Atoll Kansas Kentucky Kingman Reef Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Midway Islands Minnesota Mississippi Missouri Montana Navassa Island Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Palmyra Atoll Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Trust Territory of Pacific Utah Vermont Virgin Islands Virginia Wake Island Washington Washington D.C. West Virginia Wisconsin Wyoming - Select Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon

Zip/Postal

Country
- Select Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentine Republic Armenia Aruba Australia Austria Azerbaijan Azores Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda S Georgia Sandwich Islands Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent The Grenadines San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan, Rc Tajikistan Tanzania Thailand The Bahamas The Congo Togolese Republic Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis and Futuna Western Sahara Western Samoa Yemen Zambia Zimbabwe

Date of Birth
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Citizenship
U.S. Citizen
Not listed Please specify a value for Citizenship

Gender
- Select Option Male Female Other

Ethnicity
American Indian or Alaskan Native
Asian
Black or African American
Hawaiian or Other Pacific Islander
Hispanic or Latino
White
Not listed Please specify a value for Ethnicity

Employment status
- Select Option Unemployed Employed Full-Time Employed Part-Time Retired

Taxable income from last year
- Select Option $18,090 or Below $18,090-$24,360 $24,360-$30,630 $30,630-$43,170 $43,170-$49,440 $49,440-$55,710 $55,710-$61,980 $61,980 or More

Number in family (including self)

Are you a veteran?
- Select Option Yes No

Served at least 181 days of service?
- Select Option Yes No

Discharge other than honorable?
- Select Option Yes No

Please indicate discharge type *

Do either parents have a 4-year degree?
- Select Option Yes No

Eligible for veterans educational benefits?
- Select Option Yes No Not Sure

College graduate?
- Select Option Yes No

Attended some college?
- Select Option Yes No

Received GED?
- Select Option Yes No

High school diploma?
- Select Option Yes No

Felony Conviction/Pending Criminal Charges: Have you ever been convicted of a felony or have you been arrested for a crime for which criminal charges are pending? *
- Select Option Yes No

Thank you for disclosing. Answering YES does not necessarily disqualify you from participation in the program.

How did you find out about the VUB program? *
Website
VUB presentation or staff
Not listed Please specify a value for How did you find out about the VUB program?