Grand Canyon University

* Salutation:	Mr. Mrs. Ms. Dr. Rev.
* First Name:
* Last Name:
* Address:
Address 2:
* City:
* State / Province:	Alabama Alaska American Samoa Arizona Arkansas Armed Forces Europe Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Other
* Zip:
* Country:	United States Other
* E-mail Address:
* Phone Numbers (At least one is required.)
Day Phone:
Evening Phone:

* Highest level of education completed: - Select one - Still in HS HS Diploma or GED Some College [less than 60 credits] Associates Degree or over 60 Credits Registered Nurse Bachelor Degree Bachelor Degree w/ Cert. & Exp. BS in Nursing Master Degree or Higher

* How many college credits have you completed? - Select one - 0 1-14 15-29 30-44 45-59 60-74 75-89 90-99 100+

* Have you or your spouse ever been active in the military or reserves? Yes No

* Branch: - Select one - Army Navy Coast Guard National Guard Marines Air Force Reserve

* Status: - Select one - Active Veteran Spouse

* Who: - Select one - Me My Spouse

* Program of Interest: - Select one - B.S. in Addiction Counseling BS in Elementary Education & Special Education (Dual Major) BS in Elementary Education: Early Childhood Education BS in Elementary Education: English (With IR and Cert.) BS in Elementary Education: Math (With IR and Cert.) BS in Elementary Education: Science (With IR and Cert.) BS in Secondary Education: Business Education BS in Secondary Education: English BS in Secondary Education: Math BS in Secondary Education: Social Studies Doctor of Education in Organizational Leadership Ed.D. in Organizational Leadership with an Emphasis in Behavioral Health Ed.D. in Organizational Leadership with an Emphasis in Effective Schools Ed.D. in Organizational Leadership with an Emphasis in Higher Education Leadership Ed.D. in Organizational Leadership with an Emphasis in Instructional Leadership MED in Education Administration: School Leadership (No IR, No Cert.) MED in Elementary Education (No IR, No Cert.) MED in Elementary Education (With IR and Cert.) MED in Secondary Education (No IR, No Cert.) MED in Secondary Education (With IR and Cert.) MED in Special Education (No IR, No Cert.) MED in Special Education (With IR and Cert.) MS in Addiction Counseling MS in Marriage and Family Therapy (CA ONLY) MS in Professional Counseling

Current Employer:

* Are you a U.S. Citizen and all credits from within the U.S.? Please select an option Yes No

* If you or your spouse are a veteran, what is your/their veteran status? Not a Veteran/not applicable Chapter 30(New MGI Bill) Chapter 1606 (Reserve/Guard) Chapter 31 (Voc Rehab) Chapter 35 (Survivors) Chapter 1607 (REAP) Chapter 33 (911)

* By submitting this form I understand a representative from Grand Canyon University will contact me about my educational options within the next business day at all information I have provided in this form.