Enrollment Form

* = Required Information

APPLICATION FOR ENROLLMENT

First Time Register

Re-enroll

Program: Day

Evening

Program

ENROLLMENT FORM

SS Number:

Alien Number:

Date of Application:

Legal Name

Last Name: *

First Name: *

Middle (Name or Initial):

Maiden Name (if different):

Martial Status:

Date of Birth:

Sex:

F

M

Age:

Permanent Address: *

Home Number:

Work Number:

Name of Current Employer:

Employer's Address:

EDUCATION

I have graduated from high school

Yes

No

Year:

Name of School

I have a GED

N/A

Yes

No

Year:

Name of School

School Name/Test Center

City:

State

Enrollment Information:

Start Date *

Projected Graduation Date *

Security code