* indicates required field
Which area of study are you interested in?*	Choose One Arts and Sciences Business and Management Criminal Justice Fire Science and Emergency Management Health Sciences Higher Education and Adult Learning Information Systems and Technology Legal or Paralegal Studies Political Science, Public or Environmental Policy Teacher Education Nursing
Which program are you interested in?*	Select

First Name:*
Last Name:*
Email Address:*
Primary Phone:*
Alternate Phone:
Address:*
Address 2:
City:*
State/Province:*	Choose One Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific
Zip:*
Country:*	Choose One United States American Samoa Guam Micronesia, Federated States of Northern Mariana Islands Puerto Rico Virgin Islands (U.S.) Albania Algeria Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador England Equatorial Guinea Eritrea Espana Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea (South) Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Ireland Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Qatar Reunion Romania Russia Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa (Independent) San Marino Sao Tome and Principe Saudi Arabia Scotland Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka St. Helena St. Pierre and Miquelon Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Virgin Islands (British) Wales Wallis and Futuna Islands Western Sahara Yemen Zambia Zimbabwe
Are you a U.S. citizen or a national or permanent resident of the U.S.?*	No Yes
What is the highest level of education completed?*	Choose One Still in High School GED High School Diploma Some College (fewer than two years) Associate's degree Bachelor's degree Post-Graduate Study Master's Degree Doctoral Degree None of the Above
When are you looking to start?*	Choose One 0-1 Months 1-2 Months 2-3 Months 3 or More Months
Are you or your spouse active duty, reservist, or veteran of the U.S. Military?*	No Yes

By submitting this form, I am giving Averett University consent to contact me by email, telephone and/or text messaging at the address(es) and telephone number(s) provided above, including wireless, even if I am on a corporate, state or national Do Not Call Registry. This consent includes contact via automated means and/or pre-recorded messages. I understand that consent is not required to attend Averett University. The Averett University Privacy Policy governs our data collection policy.