Student Information Form

• Information collected on this form is for your Graduate School USA academic record and for School use only.
• All information is provided in accordance with Graduate School USA rules and within provisions established by the Family Educational Rights and Privacy Act of 1974, as amended. The Graduate School USA will not make public personally identifiable information from a student’s educational records without written consent of the student.

Legal Name

Last Name *

First Name *

Middle Name

ID Information

Date of Birth *

Title

Mailing Address

Street *

Apt#

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Contact Information

Work Phone (Include Area Code)

Cell Phone (Include Area Code) *

Email Address *

Fax (Include Area Code)

Employer

Employer's Name *

Employer's Address*

Street *

Apt#

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Course Information

Course ID *

Course Title *

Class Start Date *

Are you a substitute or transfer? *

Substitute

Transfer

If substitute, please provide name of student you are replacing:

If transferring, please provide date of previous course:

Has this course been prepaid? *

Yes

Please provide purchaser contact information below to verify proof of payment (i.e. credit card receipt, SF182, or purchase order): If the course has not been prepaid, please call the Customer Relations Center at (888) 744-4723.

Purchaser Name

Purchaser Email

Purchaser Phone Number

Date *