Thank you for your interest in FGCU's PT program!

Before you go to our On-Line Forms Center, we'd like to learn a little more about the people who visit our website. Please note that some fields are required (*) for quantitative research only unless you wish us to contact you. By telling us about your background, expectations, educational needs, and what you think of our website, we will be able to better serve our web visitors. (See our privacy policy.)

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P E R S O N A L     D A T A
First Name*
M.I.
Last Name*
Address1*
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State*	Select State/Province --- not applicable --- Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Massachusetts Maine Maryland Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming
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Phone (xxx-xxx-xxxx)*
Fax (xxx-xxx-xxxx)
E-Mail*
Date of birth (xx/xx/xx)
E D U C A T I O N A L   H I S T O R Y   &   P L A N S
Which best describes your educational status. (choose one)	I am in high school I am a high school graduate but not enrolled in college I am currently a FGCU student majoring in         (fill in blank)  I am currently enrolled in a 4-year college I am currently enrolled in a community college I hold a Bachelor's degree: None BS BA Other in I hold a graduate degree: None MS MA Other in
When would you enter FGCU's PT Program?	Fall 2007 Fall 2008 Fall 2009 Fall 2010
A B O U T   Y O U R    W E B    V I S I T (optional)
With your help, we'd like to our website an effective informational tool that meets the needs of our web visitors. Please take a few moments to complete the questions below.
Where did you hear about our program?	Local Media Web Search APTA Website Mailer Friend/Word of mouth Guidance Counselor/Advisor Event If mailer or event, please specify
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