SOFAC Member-at-Large Application

Please Type or Print:                                 E-mail address: ________________________________

Name:________________________________________________________________________

                      (Last)                                        (First)                                            (Middle Initial)

Social Security Number:_____________________________     Birth Date:___________________

Local Address:__________________________________________________________________

                                      (Street or Hall)                                           (City, State)                  (Zip Code)

Permanent Address:______________________________________________________________

                                                     (Street)                                           (City, State)                  (Zip Code)

Local Telephone:_______________________   Permanent Telephone: ______________________

Hours Completed: Missouri State:_______                              Hours Currently Enrolled:_______

                                      Transfer Credits:_______               Expected Graduation Date:_______

                                      Last Semester GPA:_______          Cumulative GPA:_______

Undergraduate Major:____________________________

Undergraduate Minor:____________________________

Why are you interested in serving on SOFAC?

Describe your future academic/career plans:

List your involvement in activities and organizations (include offices held).  You may list high school activities if you are currently a freshman.  Attach separate sheet of paper if necessary.

Signature:___________________________  Date Completed:______________

Missouri State is an AA/EEO