Request for Information

NAME
ADDRESS
CITY		STATE
PHONE		ZIP CODE
E-MAIL		Best Time to Call

If you are considering enrolling at Chemeketa, what term would you like to begin?
Year: Term: Fall Winter Spring Summer

Are you currently enrolled at another school? Yes No
Name: Location:

How much education have you completed?
Not finished high school
High school graduate or equivalent
One to two years of college
Three to four years of college
More than four years of college

I would like to learn more about:
occupational training
college transfer programs
seminars or classes for business
high school completion or basic skills courses
career counseling
distance education
financial aid
What field or subject area are you interested in:
Please send me next term's schedule of classes.
Please send me an enrollment packet.
I would like a tour of Chemeketa's campus.

What other information would you like to receive, or what questions do you have about the college?

I would not like to receive future updates and news from Chemeketa.
I would like to receive future updates and news from Chemeketa.

Due to privacy concerns we ask that you do not include your SSN or any other confidential information when submitting this form.

Information about privacy.

Updated October 2006 by the College Advancement Department.