Enrollment Application

Applicant's General Information:

All fields are required. Enter "N/A" for not applicable, if it applies to you. First Name:   Middle Name:   Last Name:   Date of Birth (M/DD/YYYY):     Home Phone:   Work Phone:   Mobile Phone:   Email Address:     Best Time To Call:   Preferred Contact Method:   Choose Answer... Phone Email Mail

Past Education:

Note: Documentation is required. High School Attended:   Graduate High School:   Choose Answer... Yes No Year of Graduation:   Did You Obtain a GED:   Choose Answer... Yes No Not Applicable College or Tech Institution:   Did You Graduate College:   Choose Answer... Yes No Not Applicable 2 or 4 Year Degree:   Choose Answer... 2 Year 4 Year Not Applicable

Permanent Address Information:

Street Address:   Street Address 2: City:   State:   Choose State... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:  

Emergency Contact Information:

Full Name:   Relationship:   Choose Answer... Mother Father Sister Brother Friend Other Street Address:   Street Address 2: City:   State:   Choose State... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:   Phone:  

Program & Location:

Location Selected:   Choose Location... Cincinnati, OH Florence, KY Frankfort, KY Lexington, KY Louisville, KY Program Selected:   Choose Program... Basic Dental Assisting Comprehensive Dental Assisting Expanded Dutied Dental Assisting How did you hear about us? Please provide the specific name of newspaper, search engine, friend, mail & etc.