First Name*
Last Name*
Street Address/PO Box
Zip Code*
Phone Number*
Alternate Phone Number
Email Address*
Best time to contact:
Days Evenings Anytime
Highest Level of Education completed*
H.S. diploma
Some college
Associate degree
Bachelor's degree
Master's degree
Year of Graduation
Number of hours towards a degree (please indicate semester/quarter hours):
I would like to attend classes:*
On campus Online Both
Campus location desired
(if known)
I am interested in:
Undergraduate degree programs
Graduate degree programs