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Travel Request Form

	REGULAR	CA	NYC/DC
Breakfast	$10.00	$12.00	$12.00
Lunch	$12.00	$13.00	$20.00
Dinner	$23.00	$30.00	$33.00
Total	$45.00	$55.00	$65.00

Request Information

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Online or On Campus

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Online or On Campus Old

Online

On Campus

On Campus Degree Type(Required)

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Choose a Program(Required)

This program is designed for registered nurses looking to advance their degree. A valid, unencumbered RN license is required to apply.

RN License Confirmation(Required)

I currently hold a valid RN license

Don't have your RN license yet? Explore other Regent programs.

High School Graduation(Required)

Are you an employee or the spouse/dependent of an employee?(Required)

Employee

Spouse/Dependent

Email Address(Required)

Company(Required)

Agency(Required)

Employee's Company(Required)

Employee's Agency(Required)

Company Email Address(Required)

Agency Email Address(Required)

Employee's Company Email Address(Required)

Employee's Agency Email Address(Required)

Employee's First Name(Required)

Employee's Last Name(Required)

Employee's First Name(Required)

Employee's Last Name(Required)

Your Email Address(Required)

First Name(Required)

Last Name(Required)

I live outside the US

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Address(Required)

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City(Required)

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State(Required)

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Zip Code(Required)

Phone(Required)

I live in Canada

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Agent's Name(Required)

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Agent GUID

Agent's Notes

I would like to start application process

By entering my first and last name above and clicking “Learn More” below, this shall constitute my electronic signature and I expressly agree that 91�� or its third party service providers may call or text me for marketing purposes at the number I provide above, including through the use of an automatic telephone dialing system and/or artificial or prerecorded voice or message according to the TCPA Terms & Conditions below. Providing this consent is not required to obtain any good or service.

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