Northwest Mississippi Community College

* = Required Field

Information Request Form

First Name*

Last Name*

Middle Initial

Date of Birth*

(MM/DD/YYYY)

Mailing Address 1*

Mailing Address 2

City*

State*

Postal Code*

Country*

Student Email Address*

Cell Phone*

(###) ###-####

Home Phone

(###) ###-####

Student Type*

Northwest Campus you Plan to Attend*

Area of Study*

for details of areas visit www.northwestms.edu/programs

Program of Study

Intended Term of Interest*

Extracurricular Interest 1

Extracurricular Interest 2