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LICENSING INFORMATION FORM

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How did you learn about CareerWay.comSM? :  
Name of Educational Institution:*   
Total Number of Students Enrolled:*   
Primary Career Center Contact Information:*     
  First Name:*   
  Last Name:*   
  Phone Number (area code first):*   
  Email Address:*   
  Mailing Address Line 1:*   
  Mailing Address Line 2:   
  City:*   
  State, province, or region:*   
  Zip or postal code:*   
  Country:*   
  Billing Information if different from above:
  Billing Address Line 1:   
  Billing Address Line 2:   
  City:   
  State, province, or region:   
  Zip or postal code:   
  Country:   
  School issued email address domain:*   
Do you have a preference for your CareerWay.comSM  URL address? (i.e., www.careerway.com/uz)
On what Web site will you place the CareerWay.comSM  link for enrolled students?:
On what Web site will you place the CareerWay.comSM  link for alumni?