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The folJowing informa�ion is requested to pracess ��our applicatic�n. <br />Name: <br />Addres <br />City/State/Zip: Q�; �[,� ; I� h 5s + t <br />Roseville Resident: � ��''`" �`� Years <br />Home Telephone: �g`� u�� Work Te�epha�e: N� <br />Home Fax: —` � ` Work Fax: � � � <br />r il <br />Home �mail: � � � � S�� � 1 � �� A-�jh _ �r`- <br />VJork EmaiI: �f/�t <br />5tudent Applicant: o Y�s, Grade [� � <br />� No <br />May we contac� you using your work email or fax: Yes /� � <br />I��a ��� <br />