1.         Contact information

Name:  __________________________

               Mailing address: __________________  

               City ___________________________  Zip Code _________

Email                             _____________________

Cell phone                     _____________________

Home phone                  _____________________

2.  Date and place of birth _________________  

3.  Voter registration number (if 18)   ____________________ County________                     

4.  Mother’s name and address:     

5.  Father’s name and address:

6.  Name of High School/ Home School Cooperative/ Other: 

7.  Cumulative GPA:    

8.  Colleges/universities to which you applied:

9.  Colleges/universities to which you have been accepted:

10.  College/university you will attend, if decided:

11.  Summary of Republican, school, community, and civic activities in which you have participated. 

12.  500 word essay on “Why I am a Republican.”