CCV Articulation Intent to Enroll Form

Division of Continuing Professional Studies
163 South Willard Street
PO Box 670, Burlington, Vermont 05402-0670 USA
(802) 865-5430 / Toll-free (888) 545-3459
E-mail: cps@champlain.edu

I plan to take my first Champlain course in the:
                             Fall Spring Summer semester of   
I plan to take:
(Check all that apply)		 Day Courses
Online Courses		 Evening Courses
Accelerarted Online Courses
 
 Information About Yourself
   
* Items required
Mr. Mrs. Miss Ms.  
First Name* Last Name* Gender  
Male Female  
 
Other names which may appear on your academic record:
 
Legal Address*      
 
City* State* Zip* Country*
 
 Mailing Address (if different)    
 
City State Zip Country
 
Home Phone* Work Phone Cell Phone Fax Number
Number you prefer to be contacted at: Home Work Cell  
   
Your Birthdate:  
       
E-mail Address*      
     
Email Usage: Daily Weekly Seldom/Never  
 
 Employment Information
 
Employer: Job Title:
 
 Mailing Address    
 
City State Zip Country
 
Type of Industry:
 
 Please indicate the CCV AS Degree program you are currently enrolled in, or have graduated from:
 
CCV Degree Enrolled in: Champlain Degree Entering:
  Accouting AS
   Accounting BS
  Business AS   Business BS
  Web Site Design and Administration AS   Computer Information Systems BS
  Network Administration AS   Computer Information Systems BS
  Computer Systems Management AS   Computer Information Systems BS
 
Anticipated Date of CCV Graduation: