First Name:
Last Name:
Street Address:
City:
State
Zip:
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Pennsylvania,US
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South Dakota,US
Tennessee,US
Texas,US
Utah,US
Vermont,US
Virginia,US
Washington,US
West Virginia,US
Wisconsin,US
Wyoming,US
Email Address:
Phone:
Cell Phone
Gender:
Household Income:
Marital Status:
select
male
female
Select
single
married
divorced
separated
widow
Number of kids
Education
High School Junior
High School Senior
College Freshman
College Sophomore
College Junior
College Senior
Associates Degree or Trade
4 year Degree
Graduate Student
Masters
Doctoral
Occupation
Work
Full time
Part time
Contractor
Retired
What Level of Education have you completed?
High School
Some College
Associates
Bachelors
Masters
Doctorates
What is your main reason to consider continuing your education?
work
promotion
earning
potential
next step in
my education
personal fulfillment
required
certification
What Level of Education do you hope to complete?
Certification
GED
Associates
Bachelors
Masters
Doctorates
Completing a Course for Personal Fulfillment
Where do you plan to complete your next level of education?
Online
College/University
Local Continuing Education Office
Technical Training or Certification site
How are you planning on funding your education?
Federal Loans
Scholarships
Grants
Personal Loans
Home Equity Loans
Pre-Paid
Employer Funde
Do you have any Student Loans Currently?
Yes
No
a. How many student loans do you have?
b. If yes, then what is your estimated loan balance?
c. Are you eligible for deferment while you continue your education?
Yes
No
I current have deferred loans
Where do you plan to complete your next level of education?
Administrative/Secretarial
IT & Computer Science
Allied Health
Legal & Paralegal
Business
MBA's Certification
Criminal Justice
Medical Transcription
Culinary Arts
Nursing
Education Social Work
Science & Engineering
Fashion Art & Design Technical
Social Work & Psychology
Healthcare Certification
Technical Trade Work
other
Web Design & Development
How often do you read for pleasure?
once a day
weekly
monthly
not enough time time
How proficient are you with a computer?
Very
I know my way around
Not so good
I am lucky if I can check my emails
10. Do you own a lap top?
Yes
No
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