Thank you for requesting information from Eastern’s School of Continuing Education. To receive your Credit and Non-credit information and/or the Fast Track Information Kit, please fill in your contact information below. If you have any other questions, please email us at cewebmail@easternct.edu or call (860) 465-5125. Please Note: That this is a secure form and we keep your contact information confidential.

1.	First Name*

2.	Last Name*

3.	Home Address and/or Mailing Address*

4.	City*

5.	State*

6.	Please, enter your 5 digit Zip Code*

7.	Day Phone Enter only numbers, no dashes or brackets!

8.	Evening Phone Enter only numbers, no dashes or brackets!

9.	Email Address*

10.	How would you like to receive your information?* In support of the University going green, the Semester Bulletin, which included the course schedule is no longer being printed. The most current information on course schedules will always be available through www.easternct.edu/ce/
	-- Please Select --EmailedMailed

11.	I would like the following information sent to me.
	The General Brochure for SCE    The link to all the current courses    The link to Fast Track    The link to all the professional non-credit career courses

12.	Are you interested in Credit and/or Non-Credit Courses? (You may check more than one answer.)*
	Credit   Non-Credit Courses

13.	Have your previously asked for information from Eastern?*
	YesNo

14.	Have you previously taken a course at Eastern?*
	YesNo

15.	If yes, please, enter your student ID or your birthdate. If entering birthdate, enter it in a mmddyyyy format. Thank you.