Personal Data Form

Last Name: First Name MI

The information on this form is for data collection purposes only. Completion of this form has no
bearing on whether or not you will be awarded a FIRST fellowship. This form will be kept
confidential and separate from your application packet. Your cooperation in completing this form
will be greatly appreciated.

SSN:
Date of Birth (MM/DD/YYYY) Female Male
(Will be asked to provide if selected)

Citizenship (check one)

U. S. Citizen Permanent Resident Other (Please Specify)

Race and/or Ethnic Origin (check one)

Note: The category that most closely reflects your recognition in the community should be used when
reporting mixed racial and/or ethnic origins.

American Indian or Alaskan Native. A person having origins in any of the original peoples of North
America, and who maintains a cultural idenfitication through tribal affiliation or community recognition.

Asian or Pacific Islander. A person having origins in any of the original peoples of the Far East,
Southeast Asia, the Indian subcontinent, or the Pacific Islands. This area includes, for example, China,
India, Japan, Korea, the Philippine Islands and Samoa.

Black, not of Hispanic Origin. A person having orgins in any of the black racial groups of Africa.

Hispanic. A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish
culture or origin, regarless of race.

White, not of Hispanic Origin. A person having origins in any of the original peoples of Europe, North
Africa , or the Middle East.

Have you ever applied for or been granted a Pell Grant? Yes No

Check here if you do not wish to provide some or all of the above information.

Please be sure to print a copy of this form for your files. Hit the submit button to send your Personal Data Form directly
to the FIRST Program's administrative office.

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