Prospect Data Entry Form

Complete the following items. When done, click the SUBMIT button. You will receive information from NSU within 5-10 business days.

- indicates a required field.

When entering a Prefix and/or Suffix, please use the following examples as a guide.

Prefix: i.e., Miss, Ms, Mr, Mrs
Suffix: i.e., Jr, Sr, III

Birthdate
Date of Birth:	Month Day Year (YYYY)

SSN/TIN/TFN
U.S. Social Security Number:	(999999999 or 999-99-9999)

Primary Address Information:

It is not necessary to enter an until date.
When inserting a US address, Address Line 1, City, State/Province, and ZIP/Postal Code are required fields. If you are entering a foreign address, Address Line 1, City and Nation are required.
Do not enter any periods, commas or other types of punctuation marks when inserting an address.
When Entering your Phone Number:
1. In the First box, enter your Area Code Only
2. In the Second box, enter your Entire 7 Digit Phone Number
3. In the Third box, enter your Extension Only (if applicable)

Primary Address
Valid From:	Month Day Year (YYYY)
Until:	Month Day Year (YYYY)
Address Line 1:
Address Line 2:
Address Line 3:
City:
State or Province:
ZIP or Postal Code:
County:
Nation:
Phone Number:	- (xxxxxx)-(xxxxxxxxxxxx) (xxxxxxxxxx extension)
International Access Code:

E-Mail Address
E-mail Address:
Verify E-mail Address:

Anticipated Entry Term
Term of Entry:

How I learned about NSU
How I Learned About Nova Southeastern University:Nova Southeastern University

Nova Southeastern University