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Fill-out the information necessary to receive information on your desired degree program.

Please allow one week for your requested materials to arrive by mail.
*Denotes required information.

 
*Degree:
*Major:
*First Name:  Middle Initial:
*Last Name:
*Address:
*City:
*State/Province:
*Country:  *Zip:
Home Phone:         Work Phone:
Fax:  E-Mail:
Marital Status:  Single:       Married:       Single Parent:
Sex:  Male:     Female:     Date of Birth:
*Occupation:
  * How long have you been employed?    Years

Select the highest education you've completed:
 
* What degrees, certifications, professional licenses,
if any, do you currently hold? List degree, major,
graduation date and number of units earned.

Where did you hear about Lacrosse University?:
  Certification: I understand that this request for information will
become part of my official application upon being accepted as
a student at Lacrosse University.
   
If you choose to print and fax this form, sign and date to authorize.