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APA Roundtable Registration

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Name:

Student Organization:

Position

Email Address

Enter a valid email address. Example: name@company.com

Cell Phone #

Enter a valid phone number. Example: 123-456-7890

Major(s)

Minor(s)

Hometown (City, State)

LMU Class Year

2010

2011

2012

2013

Student ID #

Campus Address (Building & Room #)

Date of Birth

Gender

Male

Female

Ethnicity (please specify, i.e. Chinese, Japanese/Filipino; Korean, Pakistani/Italian, etc...)

Please list additional campus activities/organizations (i.e. fraternities, service organization, study abroad, honors societies, etc)

Questions/Issues/Concerns regarding your leadership in an Asian Pacific American student organization at LMU

Thank you.