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For more information, please contact Annette Kankelborg at akankelborg@mtech.edu or 406-496-4694.

Section I

First Name:

Middle Name:

Last Name:

Date:

Address:

City:

State:

Zip:

Parent/Guardian Name:

Address:

City:

State:

Zip:

Are you a citizen of the United States? Yes No

If you are not a citizen of the United States, what is your status?

(This information is voluntary.)

Ethnicity: WhiteBlack/African American American Indian/Alaskan Native Asian Native Hawaiian or other Pacific Islander From multiple races

Section II

Are you currently in high school?
Yes No

Are you currently attending a Community/Tribal College?
Yes No

Address:

Address:

City:

City:

State:

State:

Zip:

Zip:

Graduation Date:

Graduation Date:

Overall GPA:

Overall GPA:

If you have taken either the ACT or SAT please enter your scores:

ACT Score:

SAT Score:

Composite:

Composite:

Math:

Math:

Reading:

Verbal:

Science:

Have you ever been part of a TRiO Program? Yes No

Have you ever been part of GEAR UP? Yes No

Section III

Degree Sought: Biology Chemistry Computer Science Mathematics Software Engineering Statistics