Prospect Information Form

Inquiry Form		PRINT

Please enter your information in the following forms.

- indicates a required field.

Name
First Name:
Middle Name:
Last Name:

Birthdate
Date of Birth:	Month Day Year (YYYY)

Gender
Gender:	Male	Female	Not Specified

Please select the appropriate term you are interested in attending from the pull-down menu.

Entry Term
Term of Entry:

Please select the student type that best describes your college plans. FT= full time and PT= part time.

Student Type
Student Type:

Ethnicity/Race
Ethnicity:

What is your ethnicity?

HispanicNot Hispanic

Hispanic or Latino
Not Hispanic or Latino

Hispanic or Latino

Not Hispanic or Latino

Select one or more races to indicate what you consider yourself to be.

American Indian or Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White
American Indian or Alaska Nati	Asian	Black or African American	Native Hawaiian or Other Pacif	White

For Address Line 1, please enter street address or PO Box using upper and lower case letters. Please do not use dashes when entering telephone number. Example: 1112222.

Contact Information
Address Line 1:
Address Line 2:
City:
State or Province:
ZIP or Postal Code:
County:
Nation:
Home Phone:	-

For United States phone numbers: (Area- XXX) (Phone- XXXXXXX) (Extension - (if applicable) XXXXXXXX).

Please enter complete email address. Example: Hofstra@Hofstra.edu.

E-Mail Address
E-mail Address:
Verify E-mail Address:

Please use the Look Up College Code button below to enter the information for your College/University. If you cannot locate your institution in the pull down menu, just leave this section blank.

Prior College
College Code:
Prior College Name:
Address Line 1:
Address Line 2:
Address Line 3:
City:
State or Province:
ZIP or Postal Code:
Nation:
Attended From:
Attended To:
Graduation Date:	Month Day Year (YYYY)
GPA:	(example: 9.99)
Degree:

Please select the appropriate major interest from the pull-down menu.

Major of Interest
Major:

Please indicate any special interests you may have from the list below. If you are interested in receiving a University Bulletin or semester specific class schedule, please indicate such. To select multiple materials use Ctrl+Click for PC and Command+Click for Mac.

Interests
Interests:

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Release: 8.7.2.12

Inquiry Form