CDE Request Information

1. Request Information

1. Please provide your name and address

Please provide your name and address Name: (first and last name)
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number (optional):

2. Gender

Gender Female

Male

3. Age group

Age group 18 - 21

22 - 29

30 - 39

40 - 49

50 - 59

60+

4. Area of interest

	Evening BA & BS Programs
Choose one or more	Area of interest Choose one or more Evening BA & BS Programs

5. Please notify/send me information about:

Please notify/send me information about: Information Sessions/Transfer events

6. How did you hear about us?

	Select one
Source	How did you hear about us? Source Select one

Other (please specify)

7. Have you earned college credits at Bridgewater State or any other college/university?

Have you earned college credits at Bridgewater State or any other college/university? Yes

8. If you have earned college credits, please indicate the number of credits earned:

If you have earned college credits, please indicate the number of credits earned: 1 - 12

13 - 24

24 - 54

55 - 90

90+

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