School Location: Select a location Anaheim, CA Bakersfield, CA Bell, CA Burbank, CA Castro Valley, CA Cathedral City, CA Chico, CA City of Industry, CA Concord, CA East Hartford, CT El Cajon, CA Enfield, CT Fairfield, CT Fresno, CA Hamden, CT Hayward, CA Hemet, CA Henderson, NV Huntington Beach, CA Inglewood, CA Lake Forest, CA Las Vegas, NV Lawrence, KS Layton, UT Lomita, CA Los Angeles East, CA Los Angeles West, CA Manhattan, KS Meriden, CT Moreno Valley, CA Murrieta, CA Napa, CA Niantic, CT Northampton, MA Ogden, UT Ontario, CA Overland Park, KS Palmdale, CA Paramount, CA Portland, OR Provo, UT Redding, CA Reno, NV Reseda, CA Sacramento, CA San Bernardino, CA San Diego, CA San Francisco, CA San Mateo, CA San Rafael, CA Santa Clara, CA Seaside, CA Simi Valley, CA Stockton, CA Topeka, KS Torrington, CT Victorville, CA Visalia, CA West Covina, CA Whittier, CA Wichita, KS Willimantic, CT

Code:

Personal Data

First Name:

*Last Name:

MI:

*Street address:

*City:

*State:

*Zip:

*Phone:

*e-mail:

*SSN:

*Date of birth:

*Sex:

Female

Male

*Citizenship:

US

Alien No. A-

Other

*Do you require any help or assistance to help you successfully complete the program? If so, please indicate: (If not applicable, enter N/A)

*Veteran (US):

Yes

No

Marital status:

Single

Married

Separated

Divorced

Widowed

Number of Children:

*Housing during enrollment:

With parents

Own place (Renting/Buying)

*Ethnic Group This information is required for statistical reporting to IPEDS, a contractor of the USDE.

Black

American / Alaskan Indian

Asian

Hispanic

White (not of Hispanic origin)

Educational Data

For items not applicable, enter N/A

Diplomas, Certificates or Degrees earned that are equivalent and recognized by the United States educational system

HIGH SCHOOL: (please read carefully) Check this box ONLY if you have completed U.S. High School or its equivalent

If you have not completed High School or its equivalent, provide last U.S. equivalent grade completed

*Last High School:

Dates Attended :

*Do you have a bachelor degree or above from a college or university?

Yes

No

*If yes, what is your graduation date:

Financial Aid History: Check this box ONLY if you have applied and/or received financial aid

Employment Experience

*Current or last employment:

*Position Held:

*Dates of Employment:

To

*Rate of Pay:

*(check one)

Hr

Wk

Mo.

*Street address:

*City:

*State:

*Zip:

*Phone #:

*Leaving Reason:

Family Data and Emergency Contact

*Name

Father’s

Mother’s

Contact person in an emergency

*Address

Father’s

Mother’s

Contact person in an emergency

*City/St/Zip

Father’s

Mother’s

Contact person in an emergency

*Phone

Father’s

Mother’s

Contact person in an emergency

Personal Reference (You must provide complete references that are NOT family members)

*Name

Reference 1

Reference 2

Reference 3

*Address

Reference 1

Reference 2

Reference 3

*City/St/Zip

Reference 1

Reference 2

Reference 3

*Phone

Reference 1

Reference 2

Reference 3

*What course of study are you interested in?

*How did you hear about our school? Please Select BillBoards Bus Panels Email Flyers/Mailers Friend/Family Internet-Search engine Newspaper/Magazine Pennysaver Radio TV-English TV-Cable Yellow Pages

*Males: Registered with Selective Service?

Yes

No

*Females: Pregnant?

Yes

No

*Have you ever been convicted of a misdemeanor or felony?

Yes

No

*Receive updates, special coupons, and beauty tips by E-mail:

Yes

No

By checking this box, I certify that all information on this form is true and correct to the best of my knowledge. I also understand that I may be required to provide supporting documentation of the information reported. And, by signing my name in the "Applicant's Signature" box, I confirm that I agree to the terms and regulations of this application.

*Applicant's Signature:

*Date: