1. Please provide the following contact information:

   First name
   Last name
   Street address
   Address (cont.)
   City
   State	Indiana Ohio Other
   Zip/Postal code
   Work Phone
   Home Phone
   FAX
   E-mail

   
   
   
2. Please select the area(s) of study that interest you.

   Business Administration
   Computer Information Systems
   Office Administration
   

3. Enter today's date:

   -- mm/dd/yy

4. Please add questions or comments.

   
   

Information you have submitted will be sent to Vesta Whisler, Chair of FASTNET, at the Muncie Campus of Ivy Tech State College. This information will be used only to contact you about the FASTNET Online Courses. Your personal information will not be shared with any outside parties.