PLSI Application Form-Part 1 (PDF File)

Pre-Law Summer Institute (PLSI) Application FormApplication for Summer of _______Please type or print neatly in black ink. All information is voluntary. However, failure to complete all applicable portions ofthis application may result in processing delays or make this application impossible to process.Personal DataName: Preferred Name:Last First M.I.Mailing Address:City, State, ZIP:Permanent Address:City, State, ZIP:E-Mail Address: ( ) Cell Phone: ( )Home Phone: ( ) Work Phone: ( )Date of Birth:Last 4 Digits of Social Security No.:Sex: " Male " Female Marital Status: " Single " Married Veteran: " Yes " NoNumber of Dependent Children:Full Name of Spouse:State of Residency:How Long?Tribal Affiliation: Degree: Enrollment No.:Home Agency & Address:Other Tribal Affiliation: Degree:Have you ever been convicted of a crime other than a minor traffic violation or had disciplinary action taken against you bya governmental or administrative agency?Have you ever applied to the Pre-Law Summer Institute before?" Yes " No If “Yes,” please explain on a separate sheet of paper." Yes " NoHave you ever attended the Pre-Law Summer Institute before? " Yes " NoHave you ever attended law school before? " Yes " NoEducational HistoryUndergraduate colleges/universities you have attended (beginning with the most recent).If “Yes,” what year?If “Yes,” please list law school, dates, and reason forleaving on a separate sheet of paper.School name & City, State Dates Degree ReceivedUndergraduate Major: Cumulative undergraduate GPA:PLSI Application Rev. 9/08 Page 1

Graduate schools you have attended (beginning with the most recent).School name & City, State Dates Degree ReceivedField(s) of Emphasis: Cumulative graduate GPA:Awards & Achievements - Please list any special awards, achievements, offices held, or memberships which you wouldlike to have considered.Law School Application InformationIf you have taken the Law School Admission Test (LSAT) more than once, please provide the information on each examtaken, beginning with the most recent.Date of Examination: LSAT Score: Percentile Ranking:Date of Examination: LSAT Score: Percentile Ranking:Date of Examination: LSAT Score: Percentile Ranking:Please list the law schools to which you have applied for admission:Law School Application Date Status (Admitted, ConditionallyAdmitted, Pending, Denied)Statement of Purpose and Release of InformationI hereby certify that the information supplied by me to the Pre-Law Summer Institute (PLSI) is true and correct to the bestof my knowledge. If admitted, I agree to use any funds I receive from the PLSI for my expenses while attending the PLSI,and further agree to repay, on a pro rata basis from the date of termination, any funds I have received if I withdraw or amexpelled for cause from the PLSI.I consent to the release of information in my file or other information regarding my performance in the PLSI to the BIA,other governmental agencies, law schools, or other appropriate groups for purposes including, but not limited to,complying with PLSI reporting requirements or other statistical purposes; determining my eligibility; obtaining financialassistance; completing my file; assisting in my admission to law school; or securing temporary or permanent employment.I further consent to the release by any college, university, or law school of any information they have on file regarding mewhen it is requested by the PLSI for legal purposes including, but not limited to, completing my PLSI file or studyingprogram effectiveness.Name (Printed) Signature DatePLSI Application Rev. 9/08 Page 2