(* denotes a required field) |
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General
Information |
Date: |
Wednesday, May 3rd, 2006 |
First Name*: |
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Middle Initial: |
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Last Name*: |
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Maiden Name: |
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Address*: |
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City*: |
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State*: |
Zip*:
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Home Phone*: |
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Work Phone: |
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May we contact you at work*? |
Yes
No |
Email Address*: |
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Date of Birth:
(xx/xx/19xx) |
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| 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:
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| Condition of Health - Special Health Requirements - Any Physical Problems: |
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| Known Allergies: |
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| 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:
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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
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When would you like to begin your training?*: |
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Education Information* |
High School Diploma:*: |
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Year Graduated:
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High School*: |
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City/State*: |
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GED:*: |
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Year Completed:
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State in which exam was taken*: |
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Beginning immediately
after High School, list all other training you have
started and/or completed, including
college/trade/business schools. |
School*: |
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City/State*: |
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Program of Study*: |
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Graduated: |
Yes
No
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Year attended/graduated*: |
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Type of degree/diploma earned*: |
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School*: |
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City/State*: |
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Program of Study*: |
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Graduated: |
Yes
No
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Year attended/graduated*: |
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Type of degree/diploma earned*: |
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Employment History* |
Please list job
experience, starting with the most job first. |
Employer Name & Address*: |
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Position held*: |
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Year started*: |
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Year ended*: |
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Employer Name & Address*: |
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Position held*: |
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Year started*: |
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Year ended*: |
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Employer Name & Address*: |
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Position held*: |
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Year started*: |
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Year ended*: |
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References* |
Name*: |
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Address*: |
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City/State/Zip*: |
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Phone Number*: |
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Relationship*: |
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Name*: |
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Address*: |
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City/State/Zip*: |
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Phone Number*: |
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Relationship*: |
|
Name*: |
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Address*: |
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City/State/Zip*: |
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Phone Number*: |
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Relationship*: |
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