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Phone: (706) 737-1632 | Fax: (706) 667-4355
Located in the Benet House | Email Admissions

African-American Male Initiative

Name
First Name Last Name
Middle Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
- Area Code Phone Number
Cell
- Area Code Phone Number
Birth Date
Month Day Year
Race/Ethnicity
High School
Graduation Date

High School Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Counselor's Name
High School GPA
Have you or will you earn a high school diploma by June 1, 2012

Yes No
Have you applied to Augusta State University

Yes No
In the space provided, explain why it is important for you to graduate from a college or university. Your response must contain at least 150 words.
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Georgia Regents University
2500 Walton Way
Augusta, GA 30904-2200
(706) 737-1632 | Fax: (706) 667-4355

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