<!-- https://idmanager.its.utexas.edu/eid_self_help/ -->
<form id="personalInfo" method="post" action="./">
<fieldset>
<p>
<label for="firstName"><span>*</span>First (Given) Name:</label> <input type="hidden" name="qwicap-page-id" value="D41F428A46D78104" /><input type="hidden" name="qwicap-form-id" value="9EC0EC3CD02FF862" /><input type="text" id="firstName" name="firstName" size="25" />
</p>
<p>
<label for="middleName">Middle Name:</label> <input type="text" id="middleName" name="middleName" size="25" />
</p>
<p>
<label for="lastName"><span>*</span>Last (Family) Name:</label> <input type="text" id="lastName" name="lastName" size="25" />
</p>
<p>
<label for="suffix">Generational Suffix:</label> <select name="suffix" id="suffix">
<option value="">
None
</option>
<option value="Jr">
Jr.
</option>
<option value="Sr">
Sr.
</option>
<option value="I">
I
</option>
<option value="II">
II
</option>
<option value="III">
III
</option>
<option value="IV">
IV
</option>
</select>
</p>
<p id="otherFName0">
<label for="otherFirstName">Other First Names:<br />
<span>(For example, your nickname.)</span></label> <input type="text" id="otherFirstName" name="otherFirstName" size="25" /> <input id="moreFirstNamesAdd" type="submit" value="+" name="moreFirstNames" />
</p>
<p id="otherLName0">
<label for="otherLastName">Other Last Names:<br />
<span>(For example, your maiden name.)</span></label> <input type="text" id="otherLastName" name="otherLastName" size="25" /> <input id="moreLastNamesAdd" type="submit" value="+" name="moreLastNames" />
</p>
<p>
<label><span>*</span>Date of Birth:</label> <label id="month" for="monthOfBirth">Month:</label> <select id="monthOfBirth" name="monthOfBirth">
<option value="-">
--
</option>
<option value="01">
Jan
</option>
<option value="02">
Feb
</option>
<option value="03">
Mar
</option>
<option value="04">
Apr
</option>
<option value="05">
May
</option>
<option value="06">
Jun
</option>
<option value="07">
Jul
</option>
<option value="08">
Aug
</option>
<option value="09">
Sep
</option>
<option value="10">
Oct
</option>
<option value="11">
Nov
</option>
<option value="12">
Dec
</option>
</select> <label for="dayOfBirth" id="day">Day:</label> <select id="dayOfBirth" name="dayOfBirth">
<option value="-">
--
</option>
<option value="1">
1
</option>
<option value="2">
2
</option>
<option value="3">
3
</option>
<option value="4">
4
</option>
<option value="5">
5
</option>
<option value="6">
6
</option>
<option value="7">
7
</option>
<option value="8">
8
</option>
<option value="9">
9
</option>
<option value="10">
10
</option>
<option value="11">
11
</option>
<option value="12">
12
</option>
<option value="13">
13
</option>
<option value="14">
14
</option>
<option value="15">
15
</option>
<option value="16">
16
</option>
<option value="17">
17
</option>
<option value="18">
18
</option>
<option value="19">
19
</option>
<option value="20">
20
</option>
<option value="21">
21
</option>
<option value="22">
22
</option>
<option value="23">
23
</option>
<option value="24">
24
</option>
<option value="25">
25
</option>
<option value="26">
26
</option>
<option value="27">
27
</option>
<option value="28">
28
</option>
<option value="29">
29
</option>
<option value="30">
30
</option>
<option value="31">
31
</option>
</select> <label id="year" for="yearOfBirth">Year:</label> <select id="yearOfBirth" name="yearOfBirth">
<option value="-">
--
</option>
<option value="1997">
1997
</option>
<option value="1996">
1996
</option>
<option value="1995">
1995
</option>
<option value="1994">
1994
</option>
<option value="1993">
1993
</option>
<option value="1992">
1992
</option>
<option value="1991">
1991
</option>
<option value="1990">
1990
</option>
<option value="1989">
1989
</option>
<option value="1988">
1988
</option>
<option value="1987">
1987
</option>
<option value="1986">
1986
</option>
<option value="1985">
1985
</option>
<option value="1984">
1984
</option>
<option value="1983">
1983
</option>
<option value="1982">
1982
</option>
<option value="1981">
1981
</option>
<option value="1980">
1980
</option>
<option value="1979">
1979
</option>
<option value="1978">
1978
</option>
<option value="1977">
1977
</option>
<option value="1976">
1976
</option>
<option value="1975">
1975
</option>
<option value="1974">
1974
</option>
<option value="1973">
1973
</option>
<option value="1972">
1972
</option>
<option value="1971">
1971
</option>
<option value="1970">
1970
</option>
<option value="1969">
1969
</option>
<option value="1968">
1968
</option>
<option value="1967">
1967
</option>
<option value="1966">
1966
</option>
<option value="1965">
1965
</option>
<option value="1964">
1964
</option>
<option value="1963">
1963
</option>
<option value="1962">
1962
</option>
<option value="1961">
1961
</option>
<option value="1960">
1960
</option>
<option value="1959">
1959
</option>
<option value="1958">
1958
</option>
<option value="1957">
1957
</option>
<option value="1956">
1956
</option>
<option value="1955">
1955
</option>
<option value="1954">
1954
</option>
<option value="1953">
1953
</option>
<option value="1952">
1952
</option>
<option value="1951">
1951
</option>
<option value="1950">
1950
</option>
<option value="1949">
1949
</option>
<option value="1948">
1948
</option>
<option value="1947">
1947
</option>
<option value="1946">
1946
</option>
<option value="1945">
1945
</option>
<option value="1944">
1944
</option>
<option value="1943">
1943
</option>
<option value="1942">
1942
</option>
<option value="1941">
1941
</option>
<option value="1940">
1940
</option>
<option value="1939">
1939
</option>
<option value="1938">
1938
</option>
<option value="1937">
1937
</option>
<option value="1936">
1936
</option>
<option value="1935">
1935
</option>
<option value="1934">
1934
</option>
<option value="1933">
1933
</option>
<option value="1932">
1932
</option>
<option value="1931">
1931
</option>
<option value="1930">
1930
</option>
<option value="1929">
1929
</option>
<option value="1928">
1928
</option>
<option value="1927">
1927
</option>
<option value="1926">
1926
</option>
<option value="1925">
1925
</option>
<option value="1924">
1924
</option>
<option value="1923">
1923
</option>
<option value="1922">
1922
</option>
<option value="1921">
1921
</option>
<option value="1920">
1920
</option>
<option value="1919">
1919
</option>
<option value="1918">
1918
</option>
<option value="1917">
1917
</option>
<option value="1916">
1916
</option>
<option value="1915">
1915
</option>
<option value="1914">
1914
</option>
<option value="1913">
1913
</option>
<option value="1912">
1912
</option>
</select>
</p>
<p>
<label for="cityOrTownOfBirth">City or Town of Birth:</label> <input type="text" id="cityOrTownOfBirth" name="cityOrTownOfBirth" size="25" />
</p>
<p>
<label for="stateOrProvinceOfBirth">State or Province of Birth:<br />
<span>(only if born in the US or Canada)</span></label> <select id="stateOrProvinceOfBirth" name="stateOrProvinceOfBirth">
<option value="">
Not Applicable
</option>
<option value="AL">
Alabama
</option>
<option value="AK">
Alaska
</option>
<option value="AB">
Alberta
</option>
<option value="AS">
American Samoa
</option>
<option value="AZ">
Arizona
</option>
<option value="AR">
Arkansas
</option>
<option value="BC">
British Columbia
</option>
<option value="CA">
California
</option>
<option value="CO">
Colorado
</option>
<option value="CT">
Connecticut
</option>
<option value="DE">
Delaware
</option>
<option value="DC">
District of Columbia
</option>
<option value="FL">
Florida
</option>
<option value="GA">
Georgia
</option>
<option value="GU">
Guam
</option>
<option value="HI">
Hawaii
</option>
<option value="ID">
Idaho
</option>
<option value="IL">
Illinois
</option>
<option value="IN">
Indiana
</option>
<option value="IA">
Iowa
</option>
<option value="KS">
Kansas
</option>
<option value="KY">
Kentucky
</option>
<option value="LA">
Louisiana
</option>
<option value="ME">
Maine
</option>
<option value="MB">
Manitoba
</option>
<option value="MD">
Maryland
</option>
<option value="MA">
Massachusetts
</option>
<option value="MI">
Michigan
</option>
<option value="MN">
Minnesota
</option>
<option value="MS">
Mississippi
</option>
<option value="MO">
Missouri
</option>
<option value="MT">
Montana
</option>
<option value="NE">
Nebraska
</option>
<option value="NV">
Nevada
</option>
<option value="NB">
New Brunswick
</option>
<option value="NH">
New Hampshire
</option>
<option value="NJ">
New Jersey
</option>
<option value="NM">
New Mexico
</option>
<option value="NY">
New York
</option>
<option value="NL">
Newfoundland and Labrador
</option>
<option value="NC">
North Carolina
</option>
<option value="ND">
North Dakota
</option>
<option value="MP">
Northern Mariana Islands
</option>
<option value="NT">
Northwest Territories
</option>
<option value="NS">
Nova Scotia
</option>
<option value="NU">
Nunavut
</option>
<option value="OH">
Ohio
</option>
<option value="OK">
Oklahoma
</option>
<option value="ON">
Ontario
</option>
<option value="OR">
Oregon
</option>
<option value="PA">
Pennsylvania
</option>
<option value="PE">
Prince Edward Island
</option>
<option value="PR">
Puerto Rico
</option>
<option value="QC">
Quebec
</option>
<option value="RI">
Rhode Island
</option>
<option value="SK">
Saskatchewan
</option>
<option value="SC">
South Carolina
</option>
<option value="SD">
South Dakota
</option>
<option value="TN">
Tennessee
</option>
<option value="TX">
Texas
</option>
<option value="UM">
U.S. Minor Outlying Islands
</option>
<option value="UT">
Utah
</option>
<option value="VT">
Vermont
</option>
<option value="VI">
U.S. Virgin Islands
</option>
<option value="VA">
Virginia
</option>
<option value="WA">
Washington
</option>
<option value="WV">
West Virginia
</option>
<option value="WI">
Wisconsin
</option>
<option value="WY">
Wyoming
</option>
<option value="YT">
Yukon Territory
</option>
</select>
</p>
<p>
<label for="countryOfBirth">Country of Birth:</label> <select id="countryOfBirth" name="countryOfBirth">
<option value="">
Choose...
</option>
<option value="US">
United States
</option>
<option value="AF">
Afghanistan
</option>
<option value="AX">
Åland Islands
</option>
<option value="AL">
Albania
</option>
<option value="DZ">
Algeria
</option>
<option value="AD">
Andorra
</option>
<option value="AO">
Angola
</option>
<option value="AI">
Anguilla
</option>
<option value="AQ">
Antarctica
</option>
<option value="AG">
Antigua and Barbuda
</option>
<option value="AR">
Argentina
</option>
<option value="AM">
Armenia
</option>
<option value="AW">
Aruba
</option>
<option value="AU">
Australia
</option>
<option value="AT">
Austria
</option>
<option value="AZ">
Azerbaijan
</option>
<option value="BS">
Bahamas
</option>
<option value="BH">
Bahrain
</option>
<option value="BD">
Bangladesh
</option>
<option value="BB">
Barbados
</option>
<option value="BY">
Belarus
</option>
<option value="BE">
Belgium
</option>
<option value="BZ">
Belize
</option>
<option value="BJ">
Benin
</option>
<option value="BM">
Bermuda
</option>
<option value="BT">
Bhutan
</option>
<option value="BO">
Bolivia
</option>
<option value="BA">
Bosnia and Herzogovina
</option>
<option value="BW">
Botswana
</option>
<option value="BV">
Bouvet Island
</option>
<option value="BR">
Brazil
</option>
<option value="BN">
Brunei Darussalam
</option>
<option value="BG">
Bulgaria
</option>
<option value="BF">
Burkina Faso
</option>
<option value="BI">
Burundi
</option>
<option value="KH">
Cambodia
</option>
<option value="CM">
Cameroon
</option>
<option value="CA">
Canada
</option>
<option value="CV">
Cape Verde
</option>
<option value="KY">
Cayman Islands
</option>
<option value="CF">
Central African Republic
</option>
<option value="TD">
Chad
</option>
<option value="CL">
Chile
</option>
<option value="CN">
People's Republic of China
</option>
<option value="CX">
Christmas Island
</option>
<option value="CC">
Cocos (Keeling) Islands
</option>
<option value="CO">
Colombia
</option>
<option value="KM">
Comoros
</option>
<option value="CD">
Democratic Republic of the Congo
</option>
<option value="CG">
Republic of the Congo
</option>
<option value="CK">
Cook Islands
</option>
<option value="CR">
Costa Rica
</option>
<option value="CI">
Côte d'Ivoire
</option>
<option value="HR">
Croatia
</option>
<option value="CU">
Cuba
</option>
<option value="CY">
Cyprus
</option>
<option value="CZ">
Czech Republic
</option>
<option value="DK">
Denmark
</option>
<option value="DJ">
Djibouti
</option>
<option value="DM">
Dominica
</option>
<option value="DO">
Dominican Republic
</option>
<option value="EC">
Ecuador
</option>
<option value="EG">
Egypt
</option>
<option value="SV">
El Salvador
</option>
<option value="GQ">
Equatorial Guinea
</option>
<option value="ER">
Eritrea
</option>
<option value="EE">
Estonia
</option>
<option value="ET">
Ethiopia
</option>
<option value="FK">
Falklands Islands (Malvinas)
</option>
<option value="FO">
Faroe Islands
</option>
<option value="FJ">
Fiji
</option>
<option value="FI">
Finland
</option>
<option value="FR">
France
</option>
<option value="GA">
Gabon
</option>
<option value="GM">
Gambia
</option>
<option value="GE">
Georgia
</option>
<option value="DE">
Germany
</option>
<option value="GH">
Ghana
</option>
<option value="GI">
Gibraltar
</option>
<option value="GR">
Greece
</option>
<option value="GL">
Greenland
</option>
<option value="GD">
Grenada
</option>
<option value="GP">
Guadeloupe
</option>
<option value="GT">
Guatemala
</option>
<option value="GF">
French Guiana
</option>
<option value="GN">
Guinea
</option>
<option value="GW">
Guinea-Bissau
</option>
<option value="GY">
Guyana
</option>
<option value="HT">
Haïti
</option>
<option value="HM">
Heard Island and McDonald Islands
</option>
<option value="HN">
Honduras
</option>
<option value="HK">
Hong Kong
</option>
<option value="HU">
Hungary
</option>
<option value="IS">
Iceland
</option>
<option value="IN">
India
</option>
<option value="IO">
British Indian Ocean Territory
</option>
<option value="ID">
Indonesia
</option>
<option value="IR">
Iran
</option>
<option value="IQ">
Iraq
</option>
<option value="IE">
Ireland
</option>
<option value="IL">
Israel
</option>
<option value="IT">
Italy
</option>
<option value="JM">
Jamaica
</option>
<option value="JP">
Japan
</option>
<option value="JO">
Jordan
</option>
<option value="KZ">
Kazakhstan
</option>
<option value="KE">
Kenya
</option>
<option value="KI">
Kiribati
</option>
<option value="KP">
North Korea
</option>
<option value="KR">
South Korea
</option>
<option value="KW">
Kuwait
</option>
<option value="KG">
Kyrgyzstan
</option>
<option value="LA">
Laos
</option>
<option value="LV">
Latvia
</option>
<option value="LB">
Lebanon
</option>
<option value="LS">
Lesotho
</option>
<option value="LR">
Liberia
</option>
<option value="LY">
Libya
</option>
<option value="LI">
Liechtenstein
</option>
<option value="LT">
Lithuania
</option>
<option value="LU">
Luxembourg
</option>
<option value="MK">
Macedonia
</option>
<option value="MG">
Madagascar
</option>
<option value="MW">
Malawi
</option>
<option value="MY">
Malaysia
</option>
<option value="MV">
Maldives
</option>
<option value="ML">
Mali
</option>
<option value="MT">
Malta
</option>
<option value="MH">
Marshall Islands
</option>
<option value="MQ">
Martinique
</option>
<option value="MR">
Mauritania
</option>
<option value="MU">
Mauritius
</option>
<option value="YT">
Mayotte
</option>
<option value="MX">
Mexico
</option>
<option value="FM">
Federated States of Micronesia
</option>
<option value="MD">
Moldova
</option>
<option value="MC">
Monaco
</option>
<option value="MS">
Montserrat
</option>
<option value="MA">
Morocco
</option>
<option value="MZ">
Mozambique
</option>
<option value="MM">
Myanmar
</option>
<option value="MO">
Macao
</option>
<option value="MN">
Mongolia
</option>
<option value="NA">
Namibia
</option>
<option value="NR">
Nauru
</option>
<option value="NP">
Nepal
</option>
<option value="NL">
Netherlands
</option>
<option value="AN">
Netherlands Antilles
</option>
<option value="NC">
New Caledonia
</option>
<option value="NZ">
New Zealand
</option>
<option value="NI">
Nicaragua
</option>
<option value="NE">
Niger
</option>
<option value="NG">
Nigeria
</option>
<option value="NU">
Niue
</option>
<option value="NF">
Norfolk Island
</option>
<option value="NO">
Norway
</option>
<option value="OM">
Oman
</option>
<option value="PK">
Pakistan
</option>
<option value="PW">
Palau
</option>
<option value="PS">
Palestinian Territory
</option>
<option value="PA">
Panama
</option>
<option value="PG">
Papua New Guinea
</option>
<option value="PY">
Paraguay
</option>
<option value="PE">
Peru
</option>
<option value="PH">
Philippines
</option>
<option value="PN">
Pitcairn
</option>
<option value="PL">
Poland
</option>
<option value="PF">
French Polynesia
</option>
<option value="PT">
Portugal
</option>
<option value="QA">
Qatar
</option>
<option value="RE">
Réunion
</option>
<option value="RO">
Romania
</option>
<option value="RU">
Russia
</option>
<option value="RW">
Rwanda
</option>
<option value="SH">
Saint Helena
</option>
<option value="KN">
Saint Kitts and Nevis
</option>
<option value="LC">
Saint Lucia
</option>
<option value="PM">
Saint Pierre and Miquelon
</option>
<option value="VC">
Saint Vincent and the Grenadines
</option>
<option value="WS">
Samoa
</option>
<option value="SM">
San Marino
</option>
<option value="ST">
Sao Tome and Principe
</option>
<option value="SA">
Saudi Arabia
</option>
<option value="SN">
Senegal
</option>
<option value="CS">
Serbia and Montenegro
</option>
<option value="SC">
Seychelles
</option>
<option value="SL">
Sierra Leone
</option>
<option value="SG">
Singapore
</option>
<option value="SK">
Slovakia
</option>
<option value="SI">
Slovenia
</option>
<option value="SB">
Solomon Islands
</option>
<option value="SO">
Somalia
</option>
<option value="ZA">
South Africa
</option>
<option value="GS">
South Georgia and the South Sandwich Islands
</option>
<option value="TF">
French Southern Territories
</option>
<option value="ES">
Spain
</option>
<option value="LK">
Sri Lanka
</option>
<option value="SD">
Sudan
</option>
<option value="SR">
Suriname
</option>
<option value="SJ">
Svalbard and Jan Mayen
</option>
<option value="SZ">
Swaziland
</option>
<option value="SE">
Sweden
</option>
<option value="CH">
Switzerland
</option>
<option value="SY">
Syria
</option>
<option value="TW">
Taiwan
</option>
<option value="TJ">
Tajikistan
</option>
<option value="TZ">
Tanzania
</option>
<option value="TH">
Thailand
</option>
<option value="TL">
Timor-Leste (East Timor)
</option>
<option value="TG">
Togo
</option>
<option value="TK">
Tokelau
</option>
<option value="TO">
Tonga
</option>
<option value="TT">
Trinidad and Tobago
</option>
<option value="TN">
Tunisia
</option>
<option value="TR">
Turkey
</option>
<option value="TM">
Turkmenistan
</option>
<option value="TC">
Turks and Caicos Islands
</option>
<option value="TV">
Tuvalu
</option>
<option value="UG">
Uganda
</option>
<option value="UA">
Ukraine
</option>
<option value="AE">
United Arab Emirates
</option>
<option value="GB">
United Kingdom
</option>
<option value="UY">
Uruguay
</option>
<option value="UZ">
Uzbekistan
</option>
<option value="VU">
Vanuatu
</option>
<option value="VA">
Vatican
</option>
<option value="VE">
Venezuela
</option>
<option value="VN">
Vietnam
</option>
<option value="VG">
British Virgin Islands
</option>
<option value="WF">
Wallis and Futuna
</option>
<option value="EH">
Western Sahara
</option>
<option value="YE">
Yemen
</option>
<option value="ZM">
Zambia
</option>
<option value="ZW">
Zaïre
</option>
</select>
</p>
<p>
<label for="studentSSNa">U.S. Social Security Number:<br />
<span>(<a href="javascript:newWin('why_enter_ssn.html')">Why do we ask for your SSN?</a>)</span></label> <input type="text" id="studentSSNa" name="studentSSNa" size="3" maxlength="3" /> <span> - </span> <input type="text" id="studentSSNb" name="studentSSNb" size="2" maxlength="2" /> <span> - </span> <input type="text" id="studentSSNc" name="studentSSNc" size="4" maxlength="4" />
</p>
<p>
<label for="idCardNumber">UT Austin ID Card Number:<br /></label> <input type="text" id="idCardNumber" name="idCardNumber" size="25" /> <span>(The 16-digit number on the front of your UT Austin ID card, if you have one).</span>
</p>
<p>
<label for="emailAddress">E-mail Address:</label> <input type="text" id="emailAddress" name="emailAddress" size="25" /> <span>(Use an e-mail account you will have access to several months from now. <a href="javascript:newWin('why_enter_email.html')">Why?</a>)</span>
</p>
<p>
<label for="emailAddressVerify">Verify Your E-mail Address:</label> <input type="text" id="emailAddressVerify" name="emailAddressVerify" size="25" />
</p>
</fieldset>
<p>
<a id="backSubmit" href="?back&qwicap-page-id=D41F428A46D78104" name="backSubmit">Back</a> <a href="?cancel&qwicap-page-id=D41F428A46D78104">Cancel</a> <input type="hidden" name="continue" value="Continue" /> <input type="submit" name="continue" value="Continue" />
</p>
</form>
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