EA FORM PAGE Please enable JavaScript in your browser to complete this form.First Name: *Last Name *Middle Initial:Date: *Address: *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryDate of Birth: *State of Residence: *Home Phone Number:Cell Phone Number *Email: *Program: *--select one--Non-Degree--Diploma Programs--Addiction Counseling (dip)Medical Assisting (dip)Welding (dip)--Associates Degree--AccountingAddiction Counseling (AS)BusinessCannabis Business Administration (AS)Cannabis Laboratory Sciences (AS)Healthcare SciencesHealth Information TechnologyHuman ResourcesMedical Administrative SpecialistMedical Assistant (AS)Nursing (AS)Welding (AS)--Bachelors Degrees--Addiction Counseling**Biomedical SciencesBusiness AdministrationHealthcare SciencesHealth Information ManagementMedicinal Plant SciencesNursing**--Masters Degrees--Biomedical Science (Masters)Nursing (MSN)Business Administration (MBA)Start Date:Estimated Completion Date:Class Times:High School/Facility Student graduated from:Section CampusPlease select the Campus this student will be attendingBangorXWiltonXSELECT PROGRAMThis is to populate the Tuition and Fees section for each checkbox. Make sure to only select ONE.Diploma ProgramsAddiction Counseling Diploma - DEXMedical Assisting DiplomaXWelding DiplomaXAssociate Degree ProgramsAccounting AS - DEXAccounting ASXAddiction Counseling AS - DEXAddiction Counseling ASXBusiness AS - DEXCannabis Business Administration - DEXCannabis Laboratory Science - DEXHealth Information Technology AS - DEXHealth Information Technology ASXHealthcare Sciences AS - DEXHealthcare Sciences ASXHuman Resources AS - DEXHuman Resources ASXMedical Administrative Specialist AS - DEXMedical Administrative Specialist ASXMedical Assistant AS - DEXMedical Assistant ASXNursing ASXWelding Technology AS - DEXWelding Technology ASXBachelor's Degree ProgramsAddiction Counseling BS - DEXAddiction Counseling BSXBiomedical Sciences BS - DEXBusiness Administration BS - DEXBusiness Administration BSXHealthcare Sciences BS - DEXHealthcare Sciences BSXHealth Information Management - DEXHealth Information ManagementXMedicinal Plant Sciences - DEXBSN (Nursing) - DEXMaster's Degree ProgramsBiomedical Sciences (M)XBusiness Administration (MBA) - DEXNursing (MSN) - DEXSubmit