Name        Age             Sex             Date of Birth mm/dd/yyyy

I am interested in attending:

Shawnee State University

The Ohio State University

Ohio University

None of the above

My high school grade point average is:     

I will be applying for the following scholarships:  (Check all that apply)  Academic     Athletic     Community     None

In the box below, list all extra-curricular activities in which you were involved in grades 9 - 12:

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