Prospect Data Entry Form

To receive additional information on degree and certificate programs for college credit, please complete the following.
For all other interests, including Lakeland's Holden University Center, click here.

- indicates a required field.

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

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:

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

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

To make multiple selections, hold Ctrl key (PC); command key (Mac)

How Prospect Learned About Us
How I Learned About Lakeland Community College:

It is recommended that you use the "Look Up High School Code" link if you attended a High School in the area.

Prospect High School
Home Schooled (check for yes):
OR
High School Code:
High School Name:
Address Line 1:
Address Line 2:
Address Line 3:
City:
State or Province:
ZIP or Postal Code:
Nation:
Graduation Date:	Month Day Year (YYYY)
Class Rank and Size:	/ (must be numeric)
GPA:	(example: 9.99, or A+)

Enter the anticipated term of entry into college.

Prospect Entry Term
Term of Entry:

To make multiple selections, hold Ctrl key (PC); command key (Mac)

Prospect Interests
Interests:

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/Alaska Native	Asian	Black/African American	Native Hawaiian/Other Pacific Islander	White
American Indian/Alaskan Native	Asian	Black/African American	Hawaiian/Pacific Islander	White

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Lakeland Community College

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