Northeastern Illinois University Information Request Form

Prospect Source

First Name

Last Name

Middle Name

Suffix

Birth Date

Gender

Mobile Phone

Home Phone

Email Address

Confirm Email Address

Address

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Foregin Postal Code

Recruiter:

How did you hear about us?

Contact Type

Primary High School

Organization Name (full or partial) In order to search by name, enter at least 3 characters of the name. Country

Primary College

Organization Name (full or partial) In order to search by name, enter at least 3 characters of the name. Country

What semester do you plan to apply for admission?

What student type best describes you?