Date ____________

Name___________________________________S.S.#_________________  Date of Birth  __________

Address_________________________   City  _________________    State  ________  Zip ____________

Tel# (Home)________________(Work)________________(3rd)_____________________

Name of last High School attended:___________________________  Are you a high school graduate? ______

If yes, when did you graduate?  _______________  If no, do you have your GED? _______ 

If yes, Date received   ________________    City  and State where GED taken _____________________

Other Schools or Colleges________________________________ 

Have any of your friends or relatives attended this school?     Yes _____     No _____

Marital Status:  Single____  Married ____     Separated______  Divorced _____Widowed ______

Do you have any children?        Yes _____       No_____         If yes, how many?

How will you get to school?       Bus _____   Ride with friend _____ Car _____    Other _____

How did you find out about our school?

_____ Yellow Pages     _____  Television   _____ Newspaper    _____   Mailing    _____    Agency

______ Radio    _____ Guidance Counselor  _____  Friend    _____ Other ________________

Place of Employment ________________________________________________________

Work Hours___________  Full time _____  Part time _____ 

What is your career field of interest?_______________________________________________

What is the one obstacle that would prevent you from starting school?___________________

List the reasons why you want to continue your education at our school and how it will benefit you in the future.

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