Request for Information

Basic Information

First Name*

Preferred First Name

Last Name*

Email Address*

Birthdate*

Mailing Address*

Country

Street

City

Region

Postal Code

Academic Information

With which student type do you classify?*

What would you like to study?*

When would you like to start classes?*

What would you like to tell us about?

My Contact Information

My Extracurricular Interests

My School Information

My Parent/Guardian Information

Additional Information

Home Phone

Cell Phone Number

By submitting this form, I agree to receive text messages from Alcorn State.

Extracurricular Interests (Select all that apply)

Where are you currently attending (or have most recently attended) school?

Parent/Guardian Type

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Phone