Information Request

Information Request

Thank you for your interest in learning more about our programs at Eastern New Mexico University!

- indicates a required field.

Please enter your name as it appears on your legal government documents (passport, driver's license etc.). If you prefer a different name you can enter it in the nickname section.

Prospect Name
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Nickname:

Where should we send your mail? The address you list will be used throughout the admission process.

Primary Address
Valid From:	Month Day Year (YYYY)
Until:	Month Day Year (YYYY)
Address Line 1:
Address Line 2:
Address Line 3:
City:
State or Province:
ZIP or Postal Code:
County:
Nation:
Phone Number:	- (xxxxxx)-(xxxxxxxxxxxx) (xxxxxxxxxx extension)
International Access Code:

Please choose the program you are interested in attending. If interested in leveling courses in communicative disorders then please select CDIS Leveling.

Prospect Major
Major:

Please tell us how you learned about the program you are interested in. To select multiple materials use Ctrl+Click for PC and Command+Click for Mac.

How Prospect Learned About Us
How I Learned About :

When do you plan to start?

Prospect Entry Term
Term of Entry:

Please enter your Birthday.

Prospect Birthdate
Date of Birth:	Month Day Year (YYYY)

What email would you like to receive pertinent information about ENMU?

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

Please enter information about your ethnicity/race. Please note this is an optional field but is helpful to the institution.

Prospect Ethnicity/Race
Ethnicity:

What is your ethnicity?

HispanicNot Hispanic

Hispanic or Latino
Not Hispanic or Latino

Hispanic or Latino

Not Hispanic or Latino

Select one or more races to indicate what you consider yourself to be.

American Indian or Alaska Native	Asian	Black or African American	Native Hawaiian or Other Pacific Islander	White
American Indian or Alaska Native	Asian	Black or African American	Native Hawaiian and Other Pacific Islander	White

Please select a gender.

Prospect Gender
Gender:	Male	Female	Not Specified

If you hold citizenship in a country other than the United States please complete the information below.

Prospect International Info
Nation of Citizenship:
Nation of Birth:
Native Language:
Foreign SSN:

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Release: 8.7.2.12

Information Request

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