EA FORM PAGE – Canada

First Name: *

Last Name *

Middle Initial:

Date: *

Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth: *

State/Country of Residence: *

Home Phone Number:

Cell Phone Number *

Email: *

Programs:

Start Date:

Estimated Completion Date:

Class Times:

High School/Facility Student graduated from:

Please select the Campus this student will be attending

Bangor

This is to populate the Tuition and Fees section for each checkbox. Make sure to only select ONE.

Associate Degree Programs

Nursing

Nursing - DE**