Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail

College student is interested in attending (6 Max):

Please identify and describe person soon to attend college:

Name
Age
Sex	Male Female
	Junior   Senior   Other   Grad Student

Would you like to be contacted at home or work ?

Home   Work

Enter the time of day that would be best to contact you:

How would you rate, in your opinion, your current financial situation?

bad poor average fair good

Please list any other questions or concerns you would like addressed.