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PERSONAL INFORMATION
Legal Last Name:
First Name:
Middle:
Maiden Name:
SS#
Nickname:
Street Address:
City, State
Zip Code
Home Phone
Work Phone
Fax Number:
Email Address:
Preferred method of Contact?
Home Phone     Work Phone     Fax     Email
Legal Gender:	Male     Female
Are You A U.S. Citizen?	Yes    No
Date of Birth:
If not a Citizen, list your Alien Status:

EMERGENCY CONTACT
Name:
Relationship:
Street Address:
City, State
Zip Code
Home Phone
Work Phone

EDUCATION BACKGROUND
High School:
Street Address:
City, State:
Zip Code
Graduation Year
Or GED Date:
Other Education
Dates:
Street Address:
City, State:
Zip Code

EMPLOYMENT BACKGROUND (if applicable)
Current Employer:
Work Type:
Street Address:
City, State:
Zip Code
Phone Number:

TECHNICAL SKILLS
Typing speed?
Do you write machine shorthand?	Yes No
Do you own a computer?	Yes   No
Do you have access to a computer?	Yes  No
Computer Experience - Check all that apply.
Windows    DOS    Word Perfect    Word    Excel    PowerPoint   Access   HTML   Medisoft   Other

MISCELLANEOUS
How did you hear about this course?
Promotional Code (if any):

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