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Last Name	First Name	Middle Name
Home Address	PO Box or Apt. Number	City
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State	Zip Code	County
Daytime Phone Number	Email Address
School now attending:	Academic area of interest:
Current Status: (Check all that apply.)	Undergraduate Military family member Graduate Retired Military Freshman Civilian Transfer Active duty military
Yes No		AA AS AAS
Have you recieved an Associate's degree?		If so, AA, AS or AAS?
Yes No
Have you received a bachelor's degree?
Yes No
Have you applied for admissions?	If yes, approximate date of application.
Spring Summer Fall 2008 2009 2010 2011 2012
I plan to enter:
I am interested in: (Check all that apply.)	Online courses Henderson Regional campus Correspondence courses Hopkinsville Regional campus KET telecourses Madisonville Regional campus Bachelor of Integrated Studies Paducah Regional campus Adult student information Ft. Campbell courses Scholarship information Non-Credit Courses Financial aid information Summer Camps Course catalog Community College tutoring Army ROTC program Project Graduate Other   If other, please specify:
How did you hear about us? (Check all that apply.)	Newspaper Word of Mouth Radio Other Poster/Flyer If other, please specify:
Other questions or requests:
For more information about Continuing Education & Academic Outreach, call 1-800-669-7654.