Affordable, Career-Focused Higher Education for All Qwest Employees

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First Name*

Last Name*

Street Address/PO Box*

City*

State*

Zip Code*

Work Phone Number

Home Phone Number

Cell Phone Number

Email*

Best means to contact:

Work phone Home Phone Cell phone Email

Best time to contact:

Days Evenings Anytime

Highest education level completed:

GED

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):

Gender:

Male Female

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