Name *

First Name

Last Name

DOB *

MM

DD

YYYY

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Did You Graduate? *

Yes

No

Graduation Date

MM

DD

YYYY

Did You Graduate?

Yes

No

Graduation Date

MM

DD

YYYY

Rate Your Computer Experience *

I have technical knowledge

I work with a computer everyday

I have some experience

I have not used a computer

Rate Your Typing Skills *

I am proficient

I hunt and peck with speed

Very slow

I have not touched a keyboard

Military Service *

Yes

No

Would you be willing to participate in a 15 minute Zoom call with Dr. Jeff to help improve the program and its resources? *

Yes

No