Multicultural Graduate Network

MGN Registration Form

Please fill in the following information. If you have any questions please contact us via email at mgn@grad.wisc.edu.

An * indicates a required field.

Personal Information:

* Name:

First	Middle Initial	Last
Gender:	Male Female

* This is a New Registration Updated Registration

* Local Address:

Street address

City	State	Zip
Telephone

*Email address: (prefer wisc.edu)

Academic Information:

*	Primary Degree level:
*	Primary Academic Major:
	Secondary Degree level:
	Secondary Academic Major:
*	Level:	1st YR or 1L	2nd YR or 2L	3rd YR or 3L
		4th YR	Dissertator	Post-Doc

Nationality

US Citizen or Permanent Resident? Yes No
Country of Origin:

Ethnic Heritage

Please check all that apply. Your individual information is confidential--we use the aggregate data to plan activities and events for those seeking a multicultural graduate community.

African American/Black
Cambodian Hmong Laotian Vietnamese Other Asian

American Indian or Alaskan Native
           If American Indian, please specify

Hawaiian or Pacific Islander
Mexican, Mexican American or Chicano/a
Puerto Rican Cuban
Other Hispanic or Latino/a       Please specify
White
Other        Please specify

Jorge Rodriguez, Coordinator
Multicultural Graduate Network
Room 408, Bascom Hall, 500 Lincoln Drive
Madison, WI 53706-1380
(608)265-9704
mgn@grad.wisc.edu

Multicultural Graduate Network

MGN Registration Form

* Name:

* Local Address:

Academic Information:

Nationality

Ethnic Heritage