EA FORM PAGE – Canada Please enable JavaScript in your browser to complete this form.First Name: *Last Name *Middle Initial:Student ID #: *Date: *Date of Birth: *Address: *City: *State/Province: *Zip: *State/Country of Residence: *Home Phone Number:Cell Phone Number *Email: *Programs:Nursing & Nursing – DE**Start Date:Estimated Completion Date:Program Shift: *DayEveningOnlineClass Times *Mon-Fri (Online, Asynchronous)Mon-Fri (Hybrid)Mon-Fri (On Campus)High School/Facility Student graduated from:Section CampusPlease select the Campus this student will be attendingBangorXSELECT PROGRAMThis is to populate the Tuition and Fees section for each checkbox. Make sure to only select ONE.Associate Degree ProgramsNursingXNursing – DE**XSubmit