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Primary Address
 
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Secondary Address

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Additional phone
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Gender*
Female Male
Ethnicity*
Birthdate*

99/99/1999
NSHE ID
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I.D. Type
I.D. Type-Other
Mail preference
May we include you on our mailing lists?
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Social Security Number or Individual Taxpayer Identification Number (ITIN)

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Employment Status*
Barriers to Employment*

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If you are seeking employment, in what area?*

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Highest Education Level*
Country of schooling*
Native Language
If you are requesting English as a Second Language classes, what type?
Ex-Offender?
Specific Learning Disability
Miscellaneous (Select one or more if applicable to you)

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GED/HSE/HiSET Area(s) You have Passed

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Would you like a CSN admissions counselor to contact you about continuing your college education?
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Do you have internet access at home?
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Type of computer you have at home

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Race*