Please print and complete this form. Once complete, please return this form to the EXCEL Program to the following address:

EXCEL Program
Undergraduate Studies
Kent State University
P.O. Box 5190
Kent, OH 44242

Applications will be prioritized by date received.

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Last Name: __________________________________________

First Name: __________________________________________

Middle Name: ________________________________________

Address: ____________________________________________

City: ________________________________________________

State: _____________________ Zip: _____________________

Area Code & Telephone Number: _________________________

Social Security Number: ________________________________

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The EXCEL program rooms are double occupancy in Lake Hall. This is a coed hall with men and women living in the building but on separate wings. If you have a roommate preference, indicate that person's name. Note: Your roommate must be admitted into the Exploratory major and choose to participate in the EXCEL program.

Name of Roommate Preference: __________________________________

Social Security Number: _____________________________________

Exploratory Major: ___________ Yes

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I understand the goals, expectations and requirements of EXCEL and, if selected, I agree to participate fully in the program.

Signature: ___________________________________________

Date: ______________________

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You can also fax your application to Undergraduate Studies at: (330) 672-3674

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Return your application to the address above.