CIV High School Request Information Form First Name: Last Name: Name of High School: Graduation Date (MM/YYYY): Address: City: State: Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: Phone: Cell Phone: Email: Program of Interest: --- Are you currently a registered nurse (RN)? Please SelectYesNo Do you currently have an associate's degree in Radiography? Please SelectYesNo Location: --- Disclaimer By submitting this form, I agree that ECPI University may contact me via email, telephone, wireless phone, or text message regarding its programs and offers. I understand these calls may be generated using an automated dialer. I understand that this consent is not required to purchase goods or services. Standard text and/or usage rates may apply. I understand that I may opt-out at any time from text messages by texting “stop” or unsubscribing from emails by clicking “Unsubscribe”. By this submission, I understand that if I am outside the United States, I am consenting to the transfer of my personal data to, and its storage in, the United States, and I understand that my personal data will be subject to processing in accordance with U.S. laws.
