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Information Please enter the requested information. Please note that an asterisk denotes required information.

Required - indicates a required field.
Name
Prefix:
First Name: Required
Middle Name:
Last Name: Required

Primary Address
Address Line 1:Required
Address Line 2:
Address Line 3:
City:Required
State or Province:
ZIP or Postal Code:
County:
Nation:
Phone Number: - (xxxxxx)-(xxxxxxxxxxxx) (xxxxxxxxxx extension)
International Access Code:

Birthdate
Date of Birth: Month Day Year (YYYY)

E-Mail Address
E-mail Address:Required
Verify E-mail Address:Required


High School
Home Schooled (check for yes):
OR
High School Code:
High School Name:Required
Address Line 1:
Address Line 2:
Address Line 3:
City:Required
State or Province:
ZIP or Postal Code:
Nation:
Graduation Date: Month Year (YYYY)
How you learned about Eastern

Major
Major:Required

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Release: 8.5.4