Florida Hire Ed Student Information Form



First name: Middle initial: Last name:

Last four digits of SSN:

Ten-digit primary phone:

Email address:


County: City: State: Zip:

Date of Birth (mm/dd/yyyy):




Class meeting time preferred:

Day (Chipola only)


Either day or night


Highest Level of Education Completed:

Select a Future Program of Study:

Information Technology (I.T.):

CompTIA A+ Professional Certification Training

CompTIA Network+ Professional Certification Training

CompTIA Security+ Professional Certification Training

If you are applying for an IT program, tell us about your computer experience (100 characters maximum):

Health Care (Chipola):





Are you currently enrolled in a program at UWF, Chipola College, or Florida Panhandle Technical College?:





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):

African American/Black
American Indian/Alaskan Native
Pacific Islander


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


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


How did you learn about this program?:


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):

Please submit only ONE application per program.

Office Use Only
Internal application
Advising complete