Name ____________________________________________________
               Last                                First                              Middle

Age ________ Social Security Number ____________________ Female ___ Male ___

Address: _____________________________________________________________________
                                Street                                     City                                 State                 Zip

Permanent Address: _____________________________________________________________
                               Street                                     City                                 State                 Zip

Telephone numbers: _____________________________________________________________

Electronic mail address: _____________________________________________________________

If you are a student, where are you presently enrolled? _______________________________________

Are you registering for academic credits? _____ Yes _____ No

Current GPA ______ Major ____________________________ Year of study_____________________

How did you find out about this program?

Do you have any special needs that the program director should be aware of in planning the trip?

If yes, please elaborate:

If you are not leaving with us from Fargo, N.D. from what major city would you be leaving?

Attach a copy of your most recent academic transcript and a deposit check or money order for $250 made out to Minnesota State University Moorhead. Send these materials to: Jill Holsen, Director of International Programs, 151 Flora Frick Hall, Minnesota State University Moorhead, Moorhead, MN. 56563.

Program-specific questions should be directed to: Bruce D. Roberts, Department of Anthropology and Earth Science, Minnesota State University Moorhead, Moorhead, MN. 56563; Telephone: (218) 477-2043; Fax:(218) 477-2593; E mail: robertsb@mnstate.edu