*First Name: MI

*Last Name:

*Street Address (e.g. 123 Celebrate Lane):

Street Addresss Line 2, if needed (e.g. Apt. 27, Suite B):

*City:

*State: Select below AL - Alabama AK - Alaska AZ - Arizona AR - Arkansas CA - California CO - Colorado CT - Connecticut DE - Delaware FL - Florida GA - Georgia HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VT - Vermont VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming Other overseas location *Zip Code:

*Phone Type Mobile Home Work *Telephone number: Extension (if needed)

Best time of day to reach you: 

Early morning before work (6:30 to 8:30)        Morning (8:30 to 12:00)    
Afternoon (12:00 to 5:30)     Evening (5:30 to 9:00)

*E-mail Type: Personal Work Other *E-mail address:

*Important: Please enter the name of the organization where you work:

*How did you hear about this initiative? (Important - please select one): Select one, if applicable BenefitHub Missouri Center for Nursing Alliance Computing Solutions Diebold Wincor Nixdorf (DE) Bright Future Kennedy & Associates Feducation EANGUS ARNG ANG NGB Henderson Hall USMC USMC USMCR USCG USCGR VA VR&E VA VBA Yum Brands KFC Pizza Hut Taco Bell SERDI UNIVentures Tex-X Retirement Svcs Electronic Solution Krempl Communications Making Education Possible Rosscomm Elevate ME American Ailines / US Air PSA Airlines Piedmont Airlines Americana Group Hardees TGI Fridays Baskin Robbins Grand Cafe' Costa Coffee Krispi Kreme Greenland Foods Lion Foods Chicken Tika Maestro Senior Sassi Fusion Far Eastern California Garden Farm Frites DC Ministries MGA Associates Other

If other, please enter here how you heard about us:

*Does your organization provide tuition benefits to employees?: Select below Yes - Tuition Reimbursement Yes - Up-Front Tuition Assistance No, not at this time I don't know
If yes, what is the annual cap on employee tuition benefits:

Your Academic Goal:

*Current level of education: Select one Need to complete high school High school graduate Vocational Technical College Completed some college courses Earned an Associate's Degree Earned a Bachelor's degree Completed some graduate courses Earned a Master's degree Earned a PhD, EdD or similar degree

*Degree goal: High School Completion Undergraduate Certificate Associate's Degree Bachelor's Degree Graduate Certificate Master's Degree Doctorate Degree (using federal student aid)

*Major: In what subject or field of study are you most interested:

College Credit From Colleges and Universities:

*Have you completed college courses in the past? Yes or No

If you attended college, but haven't earned a BA/BS, how many credits have you earned?
Type: Semester Hours Quarter Hours

*Are you currently pursuing a degree at a college?  Yes or No

• If the answer is yes, which college?
• What degree are you pursuing?
  

If you have already earned a degree, what degree have you earned?

*Have you ever served in the military?  Yes or No . . . If Yes, thank you for your service to this nation in uniform!

• If the answer is Yes, in which branch of the military: Army Navy Air Force Marine Corps Coast Guard Army Reserve Army National Guard Navy Reserve Air Force Reserve Air National Guard Marine Corps Reserve Coast Guard Reserve
• Current status: Veteran, Now Separated From the Military Retired Military Active Duty Military Reservist Called to Active Duty Currently Serving in the Ready Reserve
• Highest Pay Grade: E1 E2 E3 E4 E5 E6 E7 E8 E9 W1 W2 W3 W4 W5 O1 O2 O3 O4 O5 O6 O7 O8 O9 O10 GS GM WG

*Other Non-Traditional Credit: There are other ways in which people earn college credit. Let us know if any of these apply to you:

Have you ever passed a national college level examinations (AP, CLEP, DSST, TECEP, ECE or UExcel)

Have you ever earned professional certification/licenses (FAA Airframe & Powerplant, Automotive Service Excellence, Microsoft, etc.)

Have you attended professional training through a corporation or government agency.

We are here to serve you. If you have any questions, please enter them in the space below:

What level of support do you desire - Free or Premium? (Need a reminder, click here:)

*Now, select which version of support you desire?

Select one: Free Support Premium Level Support - Services & Support Up-Front Premium Level Support - Convenient three easy payments

How to submit this form:  By submitting this form, if you are a prospective student, you are agreeing to the terms of use. When you press the submit button below, your computer will clear the information from the fields above.  You are then ready to continue with the steps below.