Information Request Form

Information Request Form

Information Request Form

The following form will provide us with helpful information regarding your educational background and interests for future study at the NJ Coastal Communiversity. There is also a place for you to enter any questions or comments you may want to pass on to us.

Please fill in all information fields requested. You will be sent information specific to your requests in 1-2 business days by mail. If you use the space provided at the end of the form to ask questions, we'll respond to those by email or phone within 1-2 business days (excluding weekends). Questions requiring research may take a little longer.

Items marked with an asterisk (*) are required fields.

TODAY'S DATE
*MONTH:      *DAY:      *YEAR:

NAME
*FIRST:      *LAST:      MI:

ADDRESS

*STREET:

*CITY: *STATE: *ZIP:

*COUNTY:      Other:

PHONE NUMBERS (include area code)

*HOME

WORK

CELL

*SOCIAL SECURITY NO.:

*EMAIL ADDRESS:

1. *HOW DID YOU HEAR ABOUT THE COMMUNIVERSITY?
Other:

2. DO YOU CURRENTLY HAVE A COLLEGE DEGREE?
(If "YES" - Complete degree information below, SKIP question #3, then continue with question #4)
(If "NO" - Skip degree information below and go directly to question #3)

Degree PROGRAM COLLEGE DATE OF GRADUATION

ASSOCIATE

BACHELOR

3. HAVE YOU EVER ATTENDED, OR
ARE YOU CURRENTLY ATTENDING COLLEGE?
(If "YES" - Complete "College" and "Program" information below, then go to question #4)

COLLEGE:

PROGRAM:

NUMBER OF CREDITS EARNED:

ANTICIPATED GRADUATION DATE:

4. PROGRAM OF INTEREST AT THE COMMUNIVERSITY:

ASSOCIATE
DEGREES Other:

PREFERRED LOCATION FOR ASSOCIATE DEGREE CLASSES:

BACHELOR
DEGREES: Other:

MASTER
DEGREES Other:

GRADUATE
CERTIF. Other:

5. WHEN WOULD YOU LIKE TO BEGIN AT THE COMMUNIVERSITY?

6. WRITE ANY QUESTIONS OR COMMENTS BELOW AND CLICK "SUBMIT":