Pomona College - Personal Info Form

Welcome to the Program. To get started, please complete the following online questions. The valuable information that you provide us with will enable your counselor to learn more about you.
Note: * Required Fields

My current status is a(n):*

Please choose your username and password.
Note: You will have to re-type the same password you choose here at the bottom of this page.

Username*		Password *

6 to 15 characters		6 to 15 characters

First Name *	MI	Last Name *

E-mail Address *

Date of Birth*
(MM/DD/YYYY)

Gender*

Ethnicity_^

Address

Address Line 1:*
Address Line 2:
Address Line 3:
City: *
Postal Code: *

Home Phone: *	( )
Alternate Phone:	( )
Fax No.:	( )
State/Province:*	State is not required for international clients
Country: *


Have you previously been assigned a Special Code? If so, please enter below.
Special Code:

How did you learn about this program?*

If other, please specify:

Please use the following space to tell us 2-3 things you would like to gain from your distance career counseling experience.*

If you have a resume, please Cut and Paste it in the space provided below (do not be too concerned with the format at this time). If your resume is not readily available, you may send one to your counselor at a later date (please indicate if you are planning to do so).*

Are there any particular occupations that you are thinking about at the current time? Which occupation is your first choice? (If you are not sure, select "undecided").*

Occupation	First Choice




undecided

Please indicate any goals you may be working on which relate to your career or educational planning.*

Retype Password

IMPORTANT: By providing us with your password in this field, you confirm that you have read and agree to our Terms & Conditions of Use, Privacy Policy, Code of Ethics, Client Waiver and Informed Consent.

I agree to the terms of the Release of Information Waiver.

_^ We request this optional information regarding gender and ethnicity/ancestry in order to ensure culturally sensitive counseling.

For customer service call: 1-888-225-8248 or e-mail: helpdesk@readyminds.com