Name
Male   Female
Birth Date
E-mail Address
Preferred Mailing Address:	Residence  School Residence  Summer Residence
Residence Address:
Street
City
State	Zip
Phone
School Residence Address:
Street
City
State	Zip
Phone
Summer Residence Address:
Street
City
State	Zip
Phone

College/University:
City
State
Year	Choose One Junior Senior Graduate student
Anticipated Grad. Date	mm/dd/yy

Do you intend to take the CPA exam?

Yes No   If yes, approximate date: mm/dd/yy

Are you a WICPA Scholarship Recipient? Yes  No

Have you ever been convicted by any court or other body of a felony? Yes No
If yes, please submit details.

There is a $30 application fee/annual dues.

Credit card	Mastercard      Visa
Cardholder name
Card number
CSV/CVV#
Expiration date
Payment amount