Apply Online

(* denotes a required field)

General Information

Date:

Wednesday, May 3rd, 2006

First Name*:

Middle Initial:

Last Name*:

Maiden Name:

Address*:

City*:

State*:

   Zip*:  

Home Phone*:

Work Phone:

May we contact you at work*?

Yes No

Email Address*:
Date of Birth:
(xx/xx/19xx)
Sex: Male Female
Ethnic Background:
(for statistical purposes only) 		Caucasian Black Hispanic
Asian Native American
Have you ever been convicted of or have pleaded guilty to any crime? No Yes
If yes, please explain:
Condition of Health - Special Health Requirements - Any Physical Problems:
Known Allergies:
Are you a U.S. Veteran? Yes No
Are you a U.S. Citizen? Yes No
In case of an emergency, please contact*:

Name:
Relationship:
Phone Number:

Social Security Number*:

(For privacy reasons, this information will be gathered when you visit the school)

Driver's License Number:

(For privacy reasons, this information will be gathered when you visit the school)

Driver's License State:

(For privacy reasons, this information will be gathered when you visit the school)

Programs of Interest*

Great Lakes Medical Careers:
5100 Peach St. Office

Dental Assistant & Dental Business Administrator
Day Evening
Diagnostic Medical Sonographer
Medical Assistant with Computer Operator
Day Evening
Medical Secretary with Computer Operator
Day Evening
Pharmacy Technician
Surgical Technologist
Veterinary Assistant

Toni&Guy & Massage Therapy Careers:
930 Peach Street Campus

Cosmetology Operator
Cosmetology Teacher
Manicurist
Full-time Part-time Day Evening
Massage Therapy
Day Evening

When would you like to begin your training?*:

Education Information*

High School Diploma:*:
Year Graduated:

High School*:

City/State*:

GED:*:
Year Completed:

State in which exam was taken*:

Beginning immediately after High School, list all other training you have started and/or completed, including college/trade/business schools.

School*:

City/State*:

Program of Study*:

Graduated:

 Yes No

Year attended/graduated*:

Type of degree/diploma earned*:

School*:

City/State*:

Program of Study*:

Graduated:

 Yes No

Year attended/graduated*:

Type of degree/diploma earned*:

Employment History*

Please list job experience, starting with the most job first.

Employer Name & Address*:

Position held*:

Year started*:

Year ended*:

Employer Name & Address*:

Position held*:

Year started*:

Year ended*:

Employer Name & Address*:

Position held*:

Year started*:

Year ended*:

References*

Name*:

Address*:

City/State/Zip*:

Phone Number*:

Relationship*:

Name*:

Address*:

City/State/Zip*:

Phone Number*:

Relationship*:

Name*:

Address*:

City/State/Zip*:

Phone Number*:

Relationship*:

 
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