EA FORM PAGE

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 of Residence: *

Home Phone Number:

Cell Phone Number *

Email: *

Program: *

Start Date:

Estimated Completion Date:

Class Times:

High School/Facility Student graduated from:

Section Campus

Please select the Campus this student will be attending

Bangor

X

Wilton

X

SELECT PROGRAM

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

Diploma Programs

Addiction Counseling Diploma - DE

X

Medical Assisting Diploma

X

Welding Diploma

X

Associate Degree Programs

Accounting AS - DE

X

Accounting AS

X

Addiction Counseling AS - DE

X

Addiction Counseling AS

X

Business AS - DE

X

Cannabis Business Administration - DE

X

Cannabis Laboratory Science - DE

X

Health Information Technology AS - DE

X

Health Information Technology AS

X

Healthcare Sciences AS - DE

X

Healthcare Sciences AS

X

Human Resources AS - DE

X

Human Resources AS

X

Medical Administrative Specialist AS - DE

X

Medical Administrative Specialist AS

X

Medical Assistant AS - DE

X

Medical Assistant AS

X

Nursing AS

X

Welding Technology AS - DE

X

Welding Technology AS

X

Bachelor's Degree Programs

Addiction Counseling BS - DE

X

Addiction Counseling BS

X

Biomedical Sciences BS - DE

X

Business Administration BS - DE

X

Business Administration BS

X

Healthcare Sciences BS - DE

X

Healthcare Sciences BS

X

Health Information Management - DE

X

Health Information Management

X

Medicinal Plant Sciences - DE

X

BSN (Nursing) - DE

X

Master's Degree Programs

Biomedical Sciences (M)

X

Business Administration (MBA) - DE

X

Nursing (MSN) - DE

X