Lander University Information Request

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Student Information

Email Address *

Preferred Name

First Name *

Middle Name

Last Name *

Birthdate *

Mailing Address *

Country

Street

City

Region

Postal Code

Cell Phone Number

Academic Information

School Name (currently attending or most recent institution)

Anticipated Start Date

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Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Phone Number

Parent/Guardian Email Address