Pre-Graduation Survey

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Please complete the following online form as part of the graduation process. The data is used for statistical purposes only.

* Required completion of field. Note NA if field does not apply.

Last Name *

First Name *

ID *

Phone *

Cell Phone *

Email *

Address *

City *

State *

Zip *

Major *

Certificate or Degree

Your Future Plans *

	Continuing my education
	Name of school *

	Current employer
	Employer *
	Address *
	Phone *
	Your job title *
	Salary *	$
	Job status *	Part Time Full Time
	Hire date *
	Was this job obtained through a CNM source?
	*	Yes No
	This job utilizes the knowledge and skills learned in my CNM training/educational program
	*	Yes No

	I am not seeking employment at this time (state reason)

Today's Date *

Please PRINT THIS FORM before pressing the Submit button as confirmation