LAESA-SHPE Membership Application
 
  Fields with ( * ) are required
Courtesy Title
 First Name *
  MI
  Last Name *
 Address *
 School
  City *
  State *
  Zip *
Email Address *
Homephone *
 Workphone
 Fax
Mobile phone

 Emergency Phone *
  
Career & Ethnic Information
Date Of Birth(mm-dd-yyyy)

 Gender
Male   Female
GPA
 Degree
Class Status
 Citizenship
Major
 Ethnicity
Expected Graduation Date
  
Interested in Summer Internship Interested in Co-Op Program
Did your father go to college? Did your mother go to college?
First to go to College?  
Interested in Graduate School? If yes? What graduate degree would you like to pursue?
Graduate Students Only
Current Degrees
 Graduate Program
Advisor's Name
 Dissertation
Source of funding
 Part Time Full Time
Programs & Divisions
Please select the Division/Programs that you would like to participate in:
Public Relations Division   Retention/Recruitment Division  
Community Outreach Division   Pre-College Engineering Day  
Academic Development Division   DEAL Program (Mentor)
Information Technology Division   DEAL Program (Only if your GPA is below 2.6)  
Fundraising Division  
   
 
Can we release your information outside of LAESA-SHPE? (i.e. Companies)
Did someone refer you to Laesa? If so select the name of the person: