Full First Name MI
Last Name
Preferred Name

Date

Age Height Weight Birthdate

ADDRESS INFORMATION

Street
City     State Zip
Home Phone    Cell Phone

Email

Best Day To Call: Any Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday Best Time to Call: Anytime Morning Afternoon Evening

Spouse's Name

Mother'sName Occupation Employer          Email         

Father's Name Occupation
Employer          Email         

Parents/Guardian or Permanent Address:
Street
City     State Zip

SCHOOL INFORMATION

GPA Class Rank Class Size
Transfer GPA Transfer Credits
ACT English                     Date Taken:
ACT Math                         Date Taken:
ACT Science                   Date Taken:
ACT Writing                     Date Taken:
ACT Composite Score   Date Taken:
SAT Verbal                      Date Taken:
SAT Math                         Date Taken:
SAT Writing                      Date Taken:
SAT Compostie Score   Date Taken:

Anticipated College Major: BISI Biological Sciences BIT Business Information Technology BUS Business CH Chemistry CS Computer Science EN Environmental Engineering GE General Engineering GE General Engineering/Civil Engineering GE General Engineering/Mechanical Engineering GE General Engineering/Welding Engineering GS General Science GNST General Studies GL Geological Engineering GP Geophysical Engineering HCI Health Care Informatics NT Network Technology LS Liberal Studies MA Mathematics MTME Metallurgical Engineering MN Mining Engineering MTRN Nusring OSH Occupational Safety & Health Pre-Med/Pre-Vet PT Petroleum Engineering PTC Professional & Technical Communication SE Software Engineering UE Undecided Engineering UD Undeclared

High School Name Year of Graduation
Street             
City                  State Zip

Junior College
Street              
City                   State Zip JC Graduation Date

Guidance Counselor
School Phone           
Coach's Name          
Office Number          
Home Phone            

BASKETBALL STATS

Points Per Game FG%    FT%   
Rebounds   Assists     Vertical Jump   

Athletic Injuries:
Honors (Academic/Athletic)

Any Questions Contact Nate Larson:
Montana Tech
Men's Basketball
1300 West Park Street
Butte, MT 59701
(406) 496-4205

To Apply For Admission