Application for Enrollment in EXCEL Program

Please complete the form below. You may also download the printable version of the application form Mail $20 application fee to:

Huntington University EXCEL Program, 2303 College Avenue, Huntington, IN 46750

FIRST-TIME APPLICANTS PAY A $20 APPLICATION FEE.

Contact Information

First name
Middle Name
Last Name
Address
City
State
Zip/Postal Code
County (IN Residents Only)
Daytime Phone
Email Address
Evening Phone Number

Additional Information

Birthplace City
State
Date of birth
 
Marital Status
  
Citizenship
Religious Affiliation
Ethnicity (optional)
Did either of your parents attend school after high school?  
 
List all colleges/universities you have previously attended:

Institution
City, State
Dates Attended
Degree Earned

Employment

Current Employer
Work Telephone
Work Address
City
State
Zip/Postal Code
Job Title
Dates Employed
 How did you first become aware of the EXCEL Program?
Please include the name(s) of people who may have influenced you.

* Required Information