Student ID Number:
This is your 700# which can be found on your acceptance letter. Use only the digits when supplying your 700 number. No dashes please.

Your First Name:

Your Middle Initial:

Your Last Name:

Date of Birth: Example: YYYY/MM/DD
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Age:

Gender:
Male
Female

Address:

City:

State: Example: WV

Zip:

WVU MIX E-mail Address:
Most correspondence is done by email. Be sure to list a valid email address. Your MIX email address should look like dmolsen@mix.wvu.edu.

Other E-mail:

Another email address is required.

Home Phone: Example: (555) 555-5555

Cell phone: Example: (555) 555-5555 optional