Student Interest Form

Applicant Name

Referred by

Street Address

City

State

Zip Code

Email *

Phone

Current Status:EmployedUnemployedDislocated WorkerUnder-employed

Employer Name

Employer City

Employer State

Race

Gender

Age

Branch

Discharge Year/Type

Course Preferred

2nd Course Preferred

DaysEveningsEither

Describe any IT Computer related training or employment you have ever had

Name of High School / Year completed:

Name of Colleges or Trade Schools attended. Years completed. List any degrees/ certifications obtained to determine prior credit:

Provide a brief statement about why you are interested in IT/Computer Training:

Indicate expected funding source(s) for tuition payments?

Signature

Date

Month

Day

Year

Hours of Operation