Take the next step.
If you want more information about The Mercer Evening and Weekend Degree Program, complete the brief form below.

Please note that fields marked with an asterisk * are required.

First Name*
Last Name*
Date of Birth*
Address*
City*
State*	Select a state:     Alabama     Alaska     Arizona     Arkansas     California     Colorado     Connecticut     Delaware     DC     Florida     Georgia     Hawaii     Idaho     Illinois     Indiana     Iowa     Kansas     Kentucky     Louisiana     Maine     Maryland     Massachusetts     Michigan     Minnesota     Mississippi     Missouri     Montana     Nebraska     Nevada     New Hampshire     New Jersey     New Mexico     New York     North Carolina     North Dakota     Ohio     Oklahoma     Oregon     Pennsylvania     Rhode Island     South Carolina     South Dakota     Tennessee     Texas     Utah     Vermont     Virginia     Washington     West Virginia     Wisconsin     Wyoming
Zip*
County
Home Phone*
Work Phone
May we call you here?
	Yes         No
Cell Phone
E-mail address*
How did you hear about us?*
	Choose one:     Web     Radio     Direct Mail Flyer     Newspaper     Magazine     Television     Other
	If other, please specify:
What type of job do you currently hold?
Desired Major*	Choose one: Undergraduate Majors:     Early Childhood/Special Education     Middle Grades Education     Certification Only     Business     Criminal Justice     Human Services     Information Systems     Organization Leadership     Liberal Studies Graduate Major:     Master of Education in Educational Leadership
Desired Location*	Choose one:     Douglas County     Eastman     Henry County     Macon
	I wish to be contacted by my center coordinator to ask questions and/or schedule an appointment for a visit. I don’t wish to be contacted at this time; however, I would like to receive an admission packet.
When would you be interested in starting your course of study with us?*
	Choose one:     August 2005     October 2005     January 2006     March 2006     May 2006     Other
	If other, please specify: