First name:
Middle initial:
Last name:
Last four digits of SSN:
Ten-digit primary phone:
Email address:
Address:
County:
City:
State:
Zip:
Date of Birth (mm/dd/yyyy):
Gender:
Male
Female
Class meeting time preferred:
Day
Night
Either day or night
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Highest Level of Education Completed:
Select a Future Program of Study:
Information Technology (I.T.):
I.T. Level I
I.T. Level II
Tell us about your computer experience (100 characters maximum):
Health Care (Chipola):
ADN/RN
Paramedic
EMT
CNA
Are you currently enrolled in a program at UWF, Chipola College, or Washington-Holmes Technical Center?:
Yes
No
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Citizenship:
US Citizen/Naturalized
Lawfully Admitted Alien/Refugee
Permanent Resident
Do you have a disability?
Yes
No
If yes, please identify:
Race/Ethnicity (select all that apply):
White
African American/Black
Asian
American Indian/Alaskan Native
Pacific Islander
Hispanic
Haitian
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Are you currently employed?
Yes
No
Current or previous employer:
Current or previous employer's mailing address:
City of most recent employment:
State:
Zip:
Current or previous employer contact name:
Current or previous employer ten-digit contact phone:
Current or most recent job title:
Hire date (mm/dd/yyyy):
If applicable, then please list the date employment ended (mm/dd/yyyy):
Current or previous hourly wage: $
Current or previous annual salary (no commas): $
Description of work:
Select all that apply to your situation:
Single (number of dependents
)
Married
(number of dependents
)
Displaced homemaker
(number of dependents
)
Unemployed
(number of weeks
)
Under-employed -- working part-time or make less
than training/education would indicate
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Are you a veteran? Yes No
If you are a veteran, then please provide the following data:
Date of entry: (mm/dd/yyyy):
And exit (mm/dd/yyyy):
Type of discharge (DD214):
Read the following statements carefully --these can impact the services you receive:
I am a veteran and a copy of my DD214 is available.
I have been a veteran for less than or equal to 180 days and I was discharged under
other than dishonorable conditions
I have been a veteran for greater than 180 days and I was discharged under other than
dishonorable conditions
I am currently serving in the military.
I am a campaign veteran.
I am a disabled veteran.
I
have separated from the military within the last 48 months.
I am a spouse of a veteran and I can provide a copy of our marriage certificate.
I am a spouse of a veteran and I can provide proof of residency.
Almost all male US citizens and male aliens living in the U.S. who are 18-25 years of age are required to
register with Selective Services. Have you registered for the Selective Service?
Yes
No
N/A
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How did you learn about this program?:
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I hereby attest and certify, to the best of my knowledge, the above information is true. I also understand that this
information will be used by UWF, Chipola College and workforce development boards to track employment following
completion of the program.
Initials:
Today's Date (mm/dd/yyyy):
For: Office use only
Internal application
Advising complete
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