Information Request Form

Please enter the requested information and click the Submit button when finished.

- indicates a required field.

Enter your first and last name below. Please use correct spelling and proper capitalization.

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

Enter your complete and current home address and primary phone number. Please use correct spelling and proper capitalization.
You do not need to enter Valid From: or Until: dates.

Current Home 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:

Enter your preferred email address.

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

Enter your date of birth.

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

Enter your graduation date and year, using June 01 and the four digit year in the Graduation Date field.

Click on the Look Up High School Code button to search and select your current High School. Do not type your High School name in the High School Name field.

If you are Home Schooled check the Home Schooled checkbox.

Current 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+)

Select your area of interest. Hold down Ctrl and Click to select more than one. You are limited to 3 choices.

Area of Interest
Interests:

Select the Materials you would like to receive. Hold down Ctrl and Click to select more than one.

To view a Course catalog online please go to www.lcc.edu/academics.

To view the Summer and Fall Schedule book please go to www.lcc.edu/schedule.

Request Materials
Request Materials:

Please tell us how you learned about LCC. Hold down Ctrl and Click to select more than one.

How did you learn about LCC?
How I Learned About LCC:LCC

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LCC

Information Request Form

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