Have you ever taken a course at EMU/EMC? Yes
No

EMU ID # (if known)

Act 48 Professional Personnel ID #
7-digit ID generated by the Pennsylvania Department of Education

First Name

Middle Name

Last Name

Preferred name

Birth name

Address

Home phone

Work phone

Mobile phone

Email (preferred)

Status: Admitted to master's degree program
Not admitted to master's program
Non-degree-seeking

Gender Female Male

Birthdate

Ethnicity
Requested for Federal reporting

Employer or district

School

Position