E-Net

REQUEST FOR INFORMATION

Please complete the following form completely.  Then click on the Submit button below.  Our office will contact you within 2 business days to inform you of the expected processing time needed.

Your submission of this request form indicates your agreement with the following statement:  This information will only be used as described below and any personally identifiable information will be protected so as to remain confidential.

 

NAME: 

ORGANIZATION/DEPARTMENT/POSITION (If you are an Eastern University student, please also submit your student ID):

CONTACT INFORMATION:

         Mailing address:

         Email Address:  

         Telephone Number: 

PURPOSE OF REQUEST (Tell us how the information will be used):

INTENDED DISTRIBUTION  OF INFORMATION (Please indicate who will be seeing or using this information, for what purpose and beginning when):

DEADLINES (How soon is this information required):

INFORMATION NEEDED (Please describe, in detail, what information you need, stating time periods, student/faculty/staff groupings, etc):