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document.writeln('		</style>');
document.writeln('		<form method="post" name="form1" enctype="multipart/form-data" action="http://www.sitemason.com/form/clDS9y">');
document.writeln('<input type="hidden" name="form__current_page" value="1">		<table id="sitemason_clDS9y" class="sitemason_form" border="0" cellspacing="0" cellpadding="0" style="width:520px;" align="center">			<tr>');
document.writeln('					<td class="sitemason_body">');
document.writeln('		');
document.writeln('		<div>');
document.writeln('  <h2 class="sitemason_header" style="width:96%; border-style:none; padding-top:1px; padding-bottom:1px; padding-right:5px; padding-left:5px; margin-top:6px; margin-bottom:6px; margin-right:8px; margin-left:8px; ">');
document.writeln('    <a name="nbspnbspnbsp_Adult_Degree_Programs"></a><p style="text-align: left;"><span style="font-size: large;"><strong>&nbsp;&nbsp;&nbsp; Adult Degree Programs</strong><br />');
document.writeln('&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &gt;&gt; packet request</span></p></h2>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:100px; float:left;">');
document.writeln('      <label class="label" for="fname"><b>First Name:<b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <input type="text" style="width:150px; " name="fname">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:150px; float:left;">');
document.writeln('      <label class="label" for="lname"><b>Last Name:<b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <input type="text" style="width:200px; " name="lname">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:100px; float:left;">');
document.writeln('      <label class="label" for="address"><b>Address:<b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <input type="text" style="width:200px; " name="address">');
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document.writeln('  <br clear="all">');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:100px; float:left;">');
document.writeln('      <label class="label" for="city"><b>City:<b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <input type="text" style="width:100px; " name="city">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:50px; float:left;">');
document.writeln('      <label class="label" for="state"><b>State:<b></label>');
document.writeln('    </div>');
document.writeln('    <div class="value" align="left" style="float:left; ">');
document.writeln('      <select name="state">');
document.writeln('        <option value="AL">AL</option>');
document.writeln('        <option value="AK">AK</option>');
document.writeln('        <option value="AZ">AZ</option>');
document.writeln('        <option value="AR">AR</option>');
document.writeln('        <option value="CA">CA</option>');
document.writeln('        <option value="CO">CO</option>');
document.writeln('        <option value="CT">CT</option>');
document.writeln('        <option value="DE">DE</option>');
document.writeln('        <option value="DC">DC</option>');
document.writeln('        <option value="FL">FL</option>');
document.writeln('        <option value="GA">GA</option>');
document.writeln('        <option value="HI">HI</option>');
document.writeln('        <option value="ID">ID</option>');
document.writeln('        <option value="IL">IL</option>');
document.writeln('        <option value="IN">IN</option>');
document.writeln('        <option value="IA">IA</option>');
document.writeln('        <option value="KS">KS</option>');
document.writeln('        <option value="KY">KY</option>');
document.writeln('        <option value="LA">LA</option>');
document.writeln('        <option value="ME">ME</option>');
document.writeln('        <option value="MD">MD</option>');
document.writeln('        <option value="MA">MA</option>');
document.writeln('        <option value="MI">MI</option>');
document.writeln('        <option value="MN">MN</option>');
document.writeln('        <option value="MS">MS</option>');
document.writeln('        <option value="MO">MO</option>');
document.writeln('        <option value="MT">MT</option>');
document.writeln('        <option value="NE">NE</option>');
document.writeln('        <option value="NV">NV</option>');
document.writeln('        <option value="NH">NH</option>');
document.writeln('        <option value="NJ">NJ</option>');
document.writeln('        <option value="NM">NM</option>');
document.writeln('        <option value="NY">NY</option>');
document.writeln('        <option value="NC">NC</option>');
document.writeln('        <option value="ND">ND</option>');
document.writeln('        <option value="OH">OH</option>');
document.writeln('        <option value="OK">OK</option>');
document.writeln('        <option value="OR">OR</option>');
document.writeln('        <option value="PA">PA</option>');
document.writeln('        <option value="RI">RI</option>');
document.writeln('        <option value="SC">SC</option>');
document.writeln('        <option value="SD">SD</option>');
document.writeln('        <option value="TN" selected>TN</option>');
document.writeln('        <option value="TX">TX</option>');
document.writeln('        <option value="UT">UT</option>');
document.writeln('        <option value="VT">VT</option>');
document.writeln('        <option value="VA">VA</option>');
document.writeln('        <option value="WA">WA</option>');
document.writeln('        <option value="WV">WV</option>');
document.writeln('        <option value="WI">WI</option>');
document.writeln('        <option value="WY">WY</option>');
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document.writeln('    </div>');
document.writeln('    <input type="hidden" name="fieldname">');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:50px; float:left;">');
document.writeln('      <label class="label" for="zipcode"><b>Zip:<b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <input type="text" style="width:50px; " name="zipcode">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:100px; float:left;">');
document.writeln('      <label class="label" for="Day_Phone"><b>Day Phone:<b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <input type="text" style="width:100px; " name="Day_Phone">');
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document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:110px; float:left;">');
document.writeln('      <label class="label" for="Eve_Phone"><b>Evening Phone:<b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <input type="text" style="width:100px; " name="Eve_Phone">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:100px; float:left;">');
document.writeln('      <label class="label" for="Email"><b>Email Address:<b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <input type="text" style="width:200px; " name="Email">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div align="center" style="clear: both;" class="sitemason_body">');
document.writeln('				&nbsp;<br>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:200px; ">');
document.writeln('      <label class="label" for="Programs"><b>Which programs interest you?</b> <i> check all that apply</i></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="">');
document.writeln('      <table border="0" cellpadding="2" cellspacing="1" class="body">');
document.writeln('        <tr>');
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document.writeln('            <input type="checkbox" name="Programs" value="LIS"><span class="sitemason_body">Liberal Studies</span></td>');
document.writeln('          <td valign="top">');
document.writeln('            <input type="checkbox" name="Programs" value="RN to BSN "><span class="sitemason_body">RN to BSN (Current RN License Required)</span></td>');
document.writeln('										</tr>');
document.writeln('										<tr>');
document.writeln('									<td valign="top">');
document.writeln('            <input type="checkbox" name="Programs" value="PBBA"><span class="sitemason_body">Business</span></td>');
document.writeln('          <td valign="top">');
document.writeln('            <input type="checkbox" name="Programs" value="ACCT"><span class="sitemason_body">Accounting</span></td>');
document.writeln('										</tr>');
document.writeln('										<tr>');
document.writeln('									<td valign="top">');
document.writeln('            <input type="checkbox" name="Programs" value="MIN"><span class="sitemason_body">Ministry</span></td>');
document.writeln('          <td valign="top">');
document.writeln('            <input type="checkbox" name="Programs" value="PRM"><span class="sitemason_body">Public Relations Management</span></td>');
document.writeln('										</tr>');
document.writeln('										<tr>');
document.writeln('									<td valign="top">');
document.writeln('            <input type="checkbox" name="Programs" value="Unknown Interest"><span class="sitemason_body">Other area not on this list (enter below)</span></td>');
document.writeln('          <td valign="top">');
document.writeln('            <input type="checkbox" name="Programs" value="Unknown Interest"><span class="sitemason_body">Not sure/Undecided</span></td>');
document.writeln('										</tr>');
document.writeln('										<tr>');
document.writeln('									</tr>');
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document.writeln('      <input type="hidden" name="Programs">');
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document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="margin-left:0; text-align:left; width:225px; float:left;">');
document.writeln('      <label class="label" for="Other_area"><i>If Other, what are you looking for?</i></label>');
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document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <input type="text" style="width:150px; " name="Other_area">');
document.writeln('    </div>');
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document.writeln('  <br clear="all">');
document.writeln('  <div align="center" style="clear: both;" class="sitemason_body">');
document.writeln('				&nbsp;<br>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:210px; float:left;">');
document.writeln('      <label class="label" for="Enroll_when"><b>When do you plan on enrolling?</b></label>');
document.writeln('    </div>');
document.writeln('    <div class="value" align="left" style="float:left; ">');
document.writeln('      <select name="Enroll_when">');
document.writeln('        <option value="None Selected" selected>Select From List:</option>');
document.writeln('        <option value="Fall 1 (August)">Fall 1 (August)</option>');
document.writeln('        <option value="Fall 2 (October)">Fall 2 (October)</option>');
document.writeln('        <option value="Spring 1 (January)">Spring 1 (January)</option>');
document.writeln('        <option value="Spring 2 (March)">Spring 2 (March)</option>');
document.writeln('        <option value="Summer (June)">Summer (June)</option>');
document.writeln('        <option value="Unsure at this time">Unsure at this time</option>');
document.writeln('      </select>');
document.writeln('    </div>');
document.writeln('    <input type="hidden" name="fieldname">');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:50px; float:left;">');
document.writeln('      <label class="label" for="Year"><b>Year:</b></label>');
document.writeln('    </div>');
document.writeln('    <div class="value" align="left" style="float:left; ">');
document.writeln('      <select name="Year">');
document.writeln('        <option value="Select:" selected>Select:</option>');
document.writeln('        <option value="2010">2010</option>');
document.writeln('        <option value="2011">2011</option>');
document.writeln('      </select>');
document.writeln('    </div>');
document.writeln('    <input type="hidden" name="fieldname">');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div align="center" style="clear: both;" class="sitemason_body">');
document.writeln('				&nbsp;<br>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:425px; ">');
document.writeln('      <label class="label" for="College"><b>Please list below any colleges/universities you have attended:<b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="margin-left:50px; ">');
document.writeln('      <textarea rows="2" style="width:400px; " name="College"></textarea>');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:200px; float:left;">');
document.writeln('      <label class="label" for="Referred_By"><b>How did you hear about us?<b></label>');
document.writeln('    </div>');
document.writeln('    <div class="value" align="left" style="float:left; ">');
document.writeln('      <select name="Referred_By">');
document.writeln('        <option value="">--</option>');
document.writeln('        <option value="Radio">Radio</option>');
document.writeln('        <option value="Television">Television</option>');
document.writeln('        <option value="Website">Website</option>');
document.writeln('        <option value="Print">Newspaper/Magazine</option>');
document.writeln('        <option value="Direct Mail">Direct Mail/Postal Service</option>');
document.writeln('        <option value="Billboard">Sign/Billboard</option>');
document.writeln('        <option value="Another Belmont Student">Another Belmont Student</option>');
document.writeln('        <option value="Belmont Alumni">Belmont Alumni</option>');
document.writeln('        <option value="Family Member">Family Member</option>');
document.writeln('        <option value="Friend">Friend</option>');
document.writeln('        <option value="Co-Worker/Supervisor">Co-Worker/Supervisor</option>');
document.writeln('        <option value="Other">Other: (Please describe in space provided)</option>');
document.writeln('      </select>');
document.writeln('    </div>');
document.writeln('    <input type="hidden" name="fieldname">');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="margin-left:0; text-align:left; width:100px; float:left;">');
document.writeln('      <label class="label" for="Response_Tracking"><i>If Other:<i></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <input type="text" style="width:200px; " name="Response_Tracking">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div class="sitemason_body" align="center" style="text-align:center; ">');
document.writeln('    <input type="submit" name="submit" value="Submit">');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('</div>');
document.writeln('');
document.writeln('				</td>');
document.writeln('			</tr>');
document.writeln('			</table>');
document.writeln('		</form>');
