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document.writeln('		<form method="post" name="form1" enctype="multipart/form-data" action="http://www.sitemason.com/form/ffRY7m">');
document.writeln('<input type="hidden" name="form__current_page" value="1">		<table id="sitemason_ffRY7m" class="sitemason_form" border="0" cellspacing="0" cellpadding="0">			<tr>');
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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="Adult_Degree_Programs"></a><strong><span style="font-size: large;">Adult Degree Programs</span></strong><span style="font-size: large;"><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; &gt;&gt; Prelim Transcript Evaluation</span> <span style="font-size: large;">Request</span><br />');
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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="fname"><b>First Name:</b></label>');
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document.writeln('      <label class="label" for="lname"><b>Last Name:<b></label>');
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document.writeln('      <label class="label" for="address"><b>Mailing Address:<b></label>');
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document.writeln('      <input type="text" style="width:200px; " name="address">');
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document.writeln('      <label class="label" for="city"><b>City:</b></label>');
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document.writeln('      <input type="text" style="width:200px; " name="city">');
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document.writeln('  <div class="sitemason_body" style="float:left; ">');
document.writeln('    <div style="text-align:left; width:75px; float:left;">');
document.writeln('      <label class="label" for="state"><b>State:</b></label>');
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document.writeln('      <select name="state">');
document.writeln('        <option value="TN">TN</option>');
document.writeln('        <option value="AL">AL</option>');
document.writeln('        <option value="AK">AK</option>');
document.writeln('        <option value="AS">AS</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="FM">FM</option>');
document.writeln('        <option value="FL">FL</option>');
document.writeln('        <option value="GA">GA</option>');
document.writeln('        <option value="GU">GU</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>');
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document.writeln('        <option value="NC">NC</option>');
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document.writeln('        <option value="OH">OH</option>');
document.writeln('        <option value="OK">OK</option>');
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document.writeln('        <option value="PW">PW</option>');
document.writeln('        <option value="PA">PA</option>');
document.writeln('        <option value="PR">PR</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="TX">TX</option>');
document.writeln('        <option value="UT">UT</option>');
document.writeln('        <option value="VT">VT</option>');
document.writeln('        <option value="VI">VI</option>');
document.writeln('        <option value="VA">VA</option>');
document.writeln('        <option value="WA">WA</option>');
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document.writeln('        <option value="WI">WI</option>');
document.writeln('        <option value="WY">WY</option>');
document.writeln('        <option value="AA">AA</option>');
document.writeln('        <option value="AE">AE</option>');
document.writeln('        <option value="AP">AP</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:75px; float:left;">');
document.writeln('      <label class="label" for="zip"><b>Zip Code:</b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <input type="text" style="width:75px; " name="zip">');
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="text-align:left; width:400px; float:left; ">');
document.writeln('    <div style="text-align:left; width:450px; ">');
document.writeln('      <label class="label" for="Maiden_Name"><b>Provide maiden name or previous name on transcripts:</b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="">');
document.writeln('      <input type="text" style="width:200px; " name="Maiden_Name">');
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document.writeln('    <div style="text-align:left; width:150px; float:left;">');
document.writeln('      <label class="label" for="email"><b>E-mail Address:</b></label>');
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document.writeln('      <input type="text" style="width:200px; " name="email">');
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document.writeln('    <div style="text-align:left; width:150px; float:left;">');
document.writeln('      <label class="label" for="day_phone"><b>Daytime Phone:</b></label>');
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document.writeln('      <input type="text" style="width:200px; " name="day_phone">');
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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:450px; ">');
document.writeln('      <label class="label" for="interest"><b>Check which programs in which you are interested: </b></label>');
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document.writeln('      <table border="0" cellpadding="2" cellspacing="1" class="body">');
document.writeln('        <tr>');
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document.writeln('            <input type="checkbox" name="interest" value="ACCT"><span class="sitemason_body">Accounting</span></td>');
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document.writeln('            <input type="checkbox" name="interest" value="PBBA"><span class="sitemason_body">Business</span></td>');
document.writeln('										</tr>');
document.writeln('										<tr>');
document.writeln('									<td valign="top">');
document.writeln('            <input type="checkbox" name="interest" value="LIS"><span class="sitemason_body">Liberal Studies</span></td>');
document.writeln('          <td valign="top">');
document.writeln('            <input type="checkbox" name="interest" value="MIN"><span class="sitemason_body">Ministry</span></td>');
document.writeln('										</tr>');
document.writeln('										<tr>');
document.writeln('									<td valign="top">');
document.writeln('            <input type="checkbox" name="interest" value="PRM"><span class="sitemason_body">Public Relations Management</span></td>');
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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="enroll"><b>When do you plan on enrolling? </label>');
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document.writeln('    <div class="value" align="left" style="float:left; ">');
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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="Unknown">Unknown</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:150px; float:left;">');
document.writeln('      <label class="label" for="year"><B>Year</label>');
document.writeln('    </div>');
document.writeln('    <div class="value" align="left" style="float:left; ">');
document.writeln('      <select name="year">');
document.writeln('        <option value="2009">2009</option>');
document.writeln('        <option value="2010">2010</option>');
document.writeln('        <option value="2011">2011</option>');
document.writeln('        <option value="2012">2012</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:250px; float:left;">');
document.writeln('      <label class="label" for="colleges"><b>List previous colleges attended:</b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <textarea rows="3" style="width:200px; " name="colleges"></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:250px; float:left;">');
document.writeln('      <label class="label" for="military"><b>Any previous military experience?</b></label>');
document.writeln('    </div>');
document.writeln('    <div align="left" class="value" style="float:left; ">');
document.writeln('      <div class="sitemason_body">');
document.writeln('        <input type="checkbox" name="military" value="yes">Yes</div>');
document.writeln('      <div class="sitemason_body">');
document.writeln('        <input type="checkbox" name="military" value="no">No</div>');
document.writeln('      <input type="hidden" name="military">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <br clear="all">');
document.writeln('  <div class="sitemason_body" style="text-align:left; border-style:none; margin-bottom:14px; ">');
document.writeln('    <div><div style="text-align: left;"><em><span style="color: rgb(102, 0, 0);">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; *If Yes, send a copy of DD214 or ACE transcript.</span></em></div><br clear="all">');
document.writeln('    </div>');
document.writeln('  </div>');
document.writeln('  <div class="sitemason_body" style="width:96%; text-align:left; border-style:none; margin-bottom:14px; ">');
document.writeln('    <div>To complete the transcript evaluation request, please provide unofficial copies of all transcripts.&nbsp; You will be contacted as soon as the evaluation has been completed.<br />');
document.writeln('<br />');
document.writeln('<em><span style="color: rgb(102, 0, 0);"><strong>Please submit unofficial transcripts copies in one of the following methods:</strong></span></em><br />');
document.writeln('<br />');
document.writeln('<div style="text-align: center;"><u><strong>via E-mail:</strong></u>&nbsp;<br />');
document.writeln('kim.powell@belmont.edu<br />');
document.writeln('<br />');
document.writeln('<u><strong>via Fax:</strong></u>&nbsp; <br />');
document.writeln('615-460-6150<br />');
document.writeln('<br />');
document.writeln('<u><strong>via Mail: </strong></u><br />');
document.writeln('&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Belmont Adult Degree Programs<br />');
document.writeln('&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 1900 Belmont Blvd.<br />');
document.writeln('&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Fidelity Hall 204<br />');
document.writeln('&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Nashville, TN&nbsp; 37212</div>');
document.writeln('<br />');
document.writeln('<br /><br clear="all">');
document.writeln('    </div>');
document.writeln('  </div>');
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>');
