Name:

Position/Title:

University Status: Faculty Staff Undergraduate Student Graduate Student Technical Service Employee Administrator

University Address:

Phone: -

Campus Location: Choose location Abington Altoona Beaver Berks Delaware County Dickinson School of Law DuBois Erie Fayette Great Valley Harrisburg Hazleton Lehigh Valley McKeesport Mont Alto New Kensington Schuylkill Shenango University Park Wilkes-Barre Worthington Scranton York

Penn State E-mail Address:

Indicate briefly why you are interested in serving on the Commission on Racial / Ethnic Diversity:

Select your team preference: Academic Team Outreach Team Staff Team Student Team

List any skills, talents, expertise, or areas of interest that may pertain to specific team assignments
(e.g., staff team, student team, academic team, or outreach team).