STEPS FOR ENROLLMENT

Size: px
Start display at page:

Download "STEPS FOR ENROLLMENT"

Transcription

1 1554 Valley View Blvd. Altoona, PA Phone: (814) Fax: (814) AltoonaBeautySchool.com STEPS FOR ENROLLMENT Admissions Requirements 1. High School Diploma or GED 2. Proof of Age (Driver s License or Birth Certificate) 3. Completed ABS Enrollment Application with required add-ons: School Visits o First Visit: Tour Campus Receive School Literature Receive Financial Aid Applications Schedule Next Appointment o Second Visit Financial Planning / Aid Interview Complimentary Service (Facial or Manicure) Visit Class in Session Schedule Final Appointment o Third Visit Finalize all Financial Requirements Submit completed Enrollment Application Submit all required documents Complete Enrollment Agreement Pay $50 Enrollment Fee Your enrollment application will be reviewed. You will receive a letter of acceptance or denial within 10 business days of your third visit. If you have any questions, please call any one of our Admissions Representatives. We are here to assist you! The Admissions Representatives can be reached at: (814)

2 Student Application 1554 Valley View Blvd. Altoona, PA P: (814) F: (814) AltoonaBeautySchool.com Please check the course for which you are applying: COSMETOLOGY NAIL TECHLOGY ESTHETICS TEACHERS When do you plan to enroll at Altoona Beauty School, Inc. FULL TIME PART TIME APPLICANT INFORMATION Last Name First Name Middle Initial Date of Birth Social Security Number (required) Address Contact Number Alternate Contact Number Driver s License Number/ Issuing State PARENT INFORMATION FATHER MOTHER Issuing State SPOUSE INFORMATION

3 EDUCATION Do you have a High School Diploma? If yes, name of High School If no Diploma, do you have a GED? Have you been enrolled in Cosmetology School before? If, complete information below: School Name Dates Attended: from to How many hours did you complete? ** Provide an Official Transcript** Have you ever attended any Post-Secondary Institution? If, complete information below: School Name Dates Attended: from to Did you obtain a degree? If yes, what is your major?

4 EMPLOYMENT Name Dates Employed Work Number Name Dates Employed Work Number HEALTH FORM Name All information provided is confidential. The school may request a Doctor s Release for your student file depending upon your responses. Your responses are voluntary and in no way affect your admissions eligibility. However, by responding accurately, we can better assess your reasonable accommodation needs if necessary. Have you been diagnosed by a physician with any of the following conditions within the past six months? Check All that Apply: List of Medications taken for Treatment: (Past or Current) Alcohol, Drug Substance Abuse Carpal Tunnel Syndrome Back / Spine Condition Cancer Chronic Lung Condition Diabetes Emphysema Sight Impairment Do you wear glasses? Hearing Impairment Do you wear a Hearing Aid? Heart Condition Hepatitis A, B or C Epileptic HIV Positive Allergies: Skin, Seasonal, Etc. Please List Allergies: Other Please Explain: : Please Answer the Following: Are you Pregnant? Are all required Inoculations (shots) current? Have you ever been medically diagnosed with a learning disability, included but not limited to A.D.D. or A.D.H.D, Dyslexia or other? Name of Physician: Phone Number: I understand that if any of the above information changes during my enrollment period, I am responsible for notifying the Administrative Office and updating this form. Date

5 EMERGENCY CONTACT INFORMATION In the event of an emergency, you are authorizing Altoona Beauty School, Inc. to contact the individuals listed below. The individuals listed below are eighteen years of age or older. By providing accurate contact information, you authorize these individuals to make emergency treatment decisions if you are unable to do so. If the individuals listed are unavailable for contact, you authorize Altoona Beauty School, Inc. to make emergency medical treatment decisions on your behalf. First and Last Name Phone Number Relationship to Applicant First and Last Name Phone Number Relationship to Applicant CHILD CARE / ADDITIONAL FUNDING INFORMATION PROVIDER #1 Name Phone Number PROVIDER #2 Name Phone Number PROVIDER #1 If you are receiving funding from another organization such as OVR, TAA, WIA, Public Assistance or Veterans Training Please list your providers below. Name Case Worker / Counselor Name Phone Number Comments PROVIDER #1 Name Case Worker / Counselor Name Phone Number Comments

6 REFERENCES List two References T Living with you: REQUIRED APPLICATION SUBMISSIONS / ENCLOSURES (We will copy all documentation for you if needed) Copy of Driver s License or Birth Certificate Copy of High School Diploma or GED (Official High School Transcripts will be accepted) Essay $50 Application Fee Is Non-Refundable Can be paid with a Credit Card or Money Order only Must be paid on final visit Failure to pay Application fee will delay the proceeding of the Admissions Process TARY APPLICANT AFFIDAVIT (must be signed in presence of notary) Commonwealth of Pennsylvania, County of. I, being duly sworn, do depose and say that I am the person making the foregoing application, that I have read all the items therein carefully, and that all the statements are true and to the best of my knowledge and belief. Subscribed and sworn before me day of 20 Notary Public My Commission expires By signing below, I certify that the information provided is true and correct to the best of my knowledge. I give my permission for the faculty at Altoona Beauty School, Inc. to call any of the above listed persons in reference to my admission and attendance at Altoona Beauty School, Inc. Date

7 ESSAY Write one essay, consisting of at least 500 words. You may use additional paper if necessary. You may choose from the following topics: Briefly explain your interest in the cosmetology profession, describe yourself and how your personal traits will benefit you in this profession. Briefly explain the steps you have taken to investigate the beauty industry, when you started thinking about this as a career and your future goals and expectations once you graduate from our school. Date

Application Checklist

Application Checklist Application Checklist POSITION APPLIED FOR: Indian Preference shall not be claimed without proof. Submitted applications without copies of verification documents, unanswered questions, omitted dates, omitted

More information

Dental Assisting Program

Dental Assisting Program Dental Assisting Program Dental Assistant [The Dental Assisting Program is a 200 Hour program that meets Monday, Tuesday, Wednesday, and Thursday evenings. The class time is 5:00pm 9:00pm.] Dental Assisting

More information

Admissions Application

Admissions Application Admissions Application STAMP Pamlico Community College Post Office 185 Grantsboro, North Carolina 28529 (252) 249-1851 www.pamlicocc.edu Application for Admission INSTRUCTIONS: Complete the form in full

More information

A P P L I C A T I O N F O R A D M I S S I O N. Hospitality Inspiration Passion

A P P L I C A T I O N F O R A D M I S S I O N. Hospitality Inspiration Passion A P P L I C A T I O N F O R A D M I S S I O N Hospitality Inspiration Passion STEP 1 Application STEP 2 Goal Statement STEP 3 Reference Letters STEP 4 Entrance Test STEP 5 Transcripts STEP 6 Registration

More information

How to Enroll Yourself as an Older Youth in School

How to Enroll Yourself as an Older Youth in School How to Enroll Yourself as an Older Youth in School Education Law Center The Philadelphia Building 1315 Walnut Street, 4th Floor Philadelphia, PA 19107-4717 Phone: 215-238-6970 Education Law Center 702

More information

Medical Assisting Curriculum

Medical Assisting Curriculum Application Packet for Admission Medical Assisting Curriculum Any candidate for the Carvas College Medical Assisting program should return a fully completed, neatly filled out application to: Carvas College

More information

LICENSURE APPLICATION: OCULARIST

LICENSURE APPLICATION: OCULARIST OHIO OPTICAL DISPENSERS BOARD 77 SOUTH HIGH ST. 16 TH FLOOR COLUMBUS, OH 43215-6108 (614) 466-9709 FAX (614) 995-5392 www.optical.ohio.gov Email: odb@odb.ohio.gov LICENSURE APPLICATION: OCULARIST Application

More information

Ohio State Dental Board

Ohio State Dental Board Ohio State Dental Board 77 South High Street, 18th Floor Columbus, Ohio 43215-6135 Phone #: 614/466-2580 Fax #: 614/752-8995 www.dental.ohio.gov Dear EFDA Applicant: This application packet contains the

More information

HOW TO FILE A PETITION TO EXPUNGE JUVENILE OFFENSES

HOW TO FILE A PETITION TO EXPUNGE JUVENILE OFFENSES HOW TO FILE A PETITION TO EXPUNGE JUVENILE OFFENSES Disclaimer Neither the staff in Court Administration nor the staff in any Court office will be able to give you legal advice or help you fill out/complete

More information

DISABILITY BENEFIT APPLICATION

DISABILITY BENEFIT APPLICATION DISABILITY BENEFIT APPLICATION Ohio Police & Fire Pension Fund 140 East Town Street Columbus, OH 43215 Phone: 1-888 864 8363 Fax: (614) 628 1777 www.op f.org Please read OP&F s Member s Guide to Disability

More information

SELECTION CRITERIA Completed packet (Refer to Page 2 Checklist) with FULL payment of fee to reserve class slot (First Come First Serve Basis)

SELECTION CRITERIA Completed packet (Refer to Page 2 Checklist) with FULL payment of fee to reserve class slot (First Come First Serve Basis) Certified Nursing Assistant Training Program Class Information Fall 2013 CLASS SCHEDULE TBA- Booneville - Monday & Thursday nights (5:00-9:00) TBA - Corinth - Monday & Thursday nights (5:00-9:00) TBA -

More information

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Simsbury, Connecticut 06089 Section 1

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Simsbury, Connecticut 06089 Section 1 GROUP LIFE INSURANCE APPLICATION HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY Simsbury, Connecticut 06089 Section 1 Policyholder: American College of Emergency Physicians Policy No.: AGL-1905 Certificate

More information

DEPARTMENT OF HEALTH. APPLICATION FOR LIMITED LICENSURE and Instructions

DEPARTMENT OF HEALTH. APPLICATION FOR LIMITED LICENSURE and Instructions DEPARTMENT OF HEALTH BOARD OF CLINICAL SOCIAL WORK, MARRIAGE AND FAMILY THERAPY AND MENTAL HEALTH COUNSELING APPLICATION FOR LIMITED LICENSURE and Instructions APPLICATION FOR LIMITED LICENSURE INSTRUCTIONS

More information

Hempfield Township Board of Supervisors

Hempfield Township Board of Supervisors Hempfield Township Board of Supervisors 05/05/2015 MASSAGE THERAPIST APPLICATION Attach the following items at the time of application and renewal. Incomplete applications will not be processed or accepted.

More information

COST. CONTACT NEMCC Office of Continuing Education (662) 720-7296

COST. CONTACT NEMCC Office of Continuing Education (662) 720-7296 Certified Nursing Assistant Training Program Class Information Fall 2014 (Keep for your records) CLASS SCHEDULE September 8, 2014 - November 15, 2014 Booneville - Monday & Tuesday nights (5:30-9:30) September

More information

WASHBURN INSTITUTE OF TECHNOLOGY Surgical Technology Application for Admission

WASHBURN INSTITUTE OF TECHNOLOGY Surgical Technology Application for Admission WASHBURN INSTITUTE OF TECHNOLOGY Surgical Technology Application for Admission Washburn Institute of Technology Surgical Technology Program 5724 SW Huntoon Topeka KS 66604 785.228-6306 Fax 785.273.7080

More information

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) -

Who to call for an emergency: Name: Relationship: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - 4425 Ponce de Leon Blvd., Suite 115 Email:info@ Dr. Mercedes Gonzalez, Pediatric Dermatologist Patient Information: Patient Name: Social Security Number: / / Date of Birth: / / Sex: M / F (Circle one)

More information

Group Term Life Insurance Application

Group Term Life Insurance Application Group Term Life Insurance Application Hartford Life and Accident Insurance Company Simsbury, Connecticut 06089 Policyholder American College of Emergency Physicians Policy No. AGL-1752 Certificate No.

More information

NURSING PROGRAM APPLICATION PACKET APPLICATION DEADLINE: FEBRUARY 16, 2015 4:00 PM

NURSING PROGRAM APPLICATION PACKET APPLICATION DEADLINE: FEBRUARY 16, 2015 4:00 PM Name: Nursing Program P.O. Box 610 Holbrook, AZ 86025 (928) 532-6136 NURSING PROGRAM APPLICATION PACKET APPLICATION DEADLINE: FEBRUARY 16, 2015 4:00 PM Date: Thank you for your interest in the Northland

More information

Student & Health Information for Bates College Off-Campus Short Term Courses

Student & Health Information for Bates College Off-Campus Short Term Courses Student & Health Information for Bates College Off-Campus Short Term Courses 1. Name Program/Course Bates ID # Email Cell phone: Home Address: Date of Birth Nationality If course is going abroad, attach

More information

**Additional information may be requested at the discretion of the Board.**

**Additional information may be requested at the discretion of the Board.** Oklahoma State Board of Dentistry 2920 N Lincoln Blvd., Ste. B OKC, OK 73105 (405)522-4844 Oklahoma State Board of Dentistry CHECKLIST- DDS/ SPECIALTY/ RDH BY CREDENTIALS *In order to be eligible for licensure

More information

The apprenticeship Permit and Licensing Requirements

The apprenticeship Permit and Licensing Requirements 45-CA100 (08/22/14) STATE BOARD OF COSMETOLOGY Telephone: 717-783-7130 Fax: 717-705-5540 E-mail: st-cosmetology@state.pa.us Website:www.dos.state.pa.us/cosmet Mailing Address: PO Box 2649 Harrisburg, PA

More information

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable life insurance protection for yourself

More information

No application will be considered without an application fee of $50 (nonrefundable) Last Name First Name Middle Name Social Security Number

No application will be considered without an application fee of $50 (nonrefundable) Last Name First Name Middle Name Social Security Number APPLICATION FOR UNDERGRADUATE ADMISSION IGNATIUS UNIVERSITY (Indianapolis, Indiana) Mail to: Undergraduate Admissions office 2295 Victory Blvd. Staten Island, NY 10314 (718) 698-0700 No application will

More information

CITY OF LITTLE CANADA APPLICATION FOR MASSAGE THERAPY ESTABLISHMENT LICENSE

CITY OF LITTLE CANADA APPLICATION FOR MASSAGE THERAPY ESTABLISHMENT LICENSE CITY OF LITTLE CANADA APPLICATION FOR MASSAGE THERAPY ESTABLISHMENT LICENSE Massage Therapy Principal Use License Fee $300 Massage Therapy Accessory Use License Fee $100 (Accessory or incidental use to

More information

Washburn Institute of Technology

Washburn Institute of Technology Washburn Institute of Technology Practical Nursing Application for Admission Washburn Institute of Technology Practical Nursing Program 5724 SW Huntoon Topeka KS 66604 785. 228.6306 Fax 785.273.7080 Date:

More information

HMIS Annual Assessment Form

HMIS Annual Assessment Form Name/Identification and Contact Information: Legal First Name: Legal Last Name: Program Name: Case Manager: HMIS consent form signed? Middle Name: Suffix: Program Entry Date: / / Date of Assessment: /

More information

APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS

APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS 1. Please read the enclosed brochure for important information. 2. You may use this application to apply for Special Care for adults

More information

SUSQUEHANNA COUNTY CAREER AND TECHNOLOGY CENTER PO BOX 100, SCHOOL HOUSE ROAD DIMOCK, PA 18816-0100 PHONE: (570)278-9229 FAX: (570)278-3913

SUSQUEHANNA COUNTY CAREER AND TECHNOLOGY CENTER PO BOX 100, SCHOOL HOUSE ROAD DIMOCK, PA 18816-0100 PHONE: (570)278-9229 FAX: (570)278-3913 To: From: Re: Applicant Alice M. Davis, Ph.D. Executive Director School Counselor Director Nurse Aide Training Program Thank you for your interest in our program. Listed below is information that will

More information

Please note that all dates, times and fees listed are subject to change without notice.

Please note that all dates, times and fees listed are subject to change without notice. May 21, 2012 Dear Prospective Student: Thank you for considering Simi Valley Adult School and Career Institute as you pursue a career as an X-ray Technician. This is a limited permit program that prepares

More information

CHILDREN AND YOUTH CASEWORKERS EDUCATION SCREEN

CHILDREN AND YOUTH CASEWORKERS EDUCATION SCREEN CHILDREN AND YOUTH CASEWORKERS EDUCATION SCREEN When a child enters the child welfare system, and at each of his/her six month reviews, a caseworker shall use this Education Screen to assess a child s

More information

Project H.E.A.L.T.H Certified Nursing Assistant Program for Youth

Project H.E.A.L.T.H Certified Nursing Assistant Program for Youth Project H.E.A.L.T.H Certified Nursing Assistant Program for Youth PROGRAM INFORMATION The Certified Nursing Assistant Program is an accelerated curriculum that prepares students to pass the Massachusetts

More information

JESUS CARES MINISTRIES INTERVIEW SHEET TODAY'S DATE. NAME PHONE AGE first middle last ADDRESS CITY STATE ZIP HEIGHT WEIGHT HAIR COLOR EYE COLOR RACE

JESUS CARES MINISTRIES INTERVIEW SHEET TODAY'S DATE. NAME PHONE AGE first middle last ADDRESS CITY STATE ZIP HEIGHT WEIGHT HAIR COLOR EYE COLOR RACE JESUS CARES MINISTRIES INTERVIEW SHEET TODAY'S DATE NAME PHONE AGE first middle last ADDRESS CITY STATE ZIP HEIGHT WEIGHT HAIR COLOR EYE COLOR RACE BIRTHDAY DATE MARITAL STATUS SOC SECURITY # DO YOU HAVE

More information

Completing your Personal Health Application New York Applicants

Completing your Personal Health Application New York Applicants Completing your Personal Health Application New York Applicants Purpose These instructions will help you to complete your Personal Health Application. This will help ensure that your application is processed

More information

Civil Service Employees Benefit Association 67182-7. Address City State Zip. Place of Birth Home/Cell Phone # Work Phone # E-mail Address

Civil Service Employees Benefit Association 67182-7. Address City State Zip. Place of Birth Home/Cell Phone # Work Phone # E-mail Address Group Term Life Application for 10-Year or 20-Year Level Term Rate Please complete the entire application. If completing this application in paper format, please print clearly in dark ink and mail to WrightUSA

More information

Emergency Services Academy Ltd. 2 nd Floor, 161 Broadway Boulevard Sherwood Park AB T8H 2A8

Emergency Services Academy Ltd. 2 nd Floor, 161 Broadway Boulevard Sherwood Park AB T8H 2A8 Emergency Medical Technician/Primary Care Paramedic (EMT/PCP) Program Application Package Please ensure you read all of the instructions completely before submitting your application for an EMT/PCP Program.

More information

Montgomery County Community College. Medical Assisting Information Packet

Montgomery County Community College. Medical Assisting Information Packet 1 Montgomery County Community College Medical Assisting Information Packet This Information Packet provides the prospective applicant with information about the Medical Assisting Program. Additional information

More information

Application for In-State Tuition Rate thru Maryland Dream Act

Application for In-State Tuition Rate thru Maryland Dream Act Application for In-State Tuition Rate thru Maryland Dream Act Application form is downloadable at http://www.aacc.edu/recreg/forms.cfm 101 College Parkway Arnold, Maryland 21012-1895 Records and Registration

More information

US Agency for Christian Counseling Credentials and Accreditation 5205 South Orange Avenue # 202, Orlando, FL 32809

US Agency for Christian Counseling Credentials and Accreditation 5205 South Orange Avenue # 202, Orlando, FL 32809 US Agency for Christian Counseling Credentials and Accreditation 5205 South Orange Avenue # 202, Orlando, FL 32809 Licensing & Certification The US Agency for Christian Counseling Credentials and Accreditation

More information

APPLICATION FOR A TEACHER S LICENSE - DENTISTRY OR DENTAL HYGIENE

APPLICATION FOR A TEACHER S LICENSE - DENTISTRY OR DENTAL HYGIENE Maryland State Board of Dental Examiners Spring Grove Hospital Center Benjamin Rush Building 55 Wade Avenue Catonsville, Maryland 21228 (410) 402-8510 APPLICATION FOR A TEACHER S LICENSE - DENTISTRY OR

More information

Email Address: _ Pre-Disability Earnings: $ City: State: Zip Code: Beneficiary Print full name & relationship to you

Email Address: _ Pre-Disability Earnings: $ City: State: Zip Code: Beneficiary Print full name & relationship to you GROUP DISABILITY INCOME INSURANCE APPLICATION HARTFORD LIFE INSURANCE COMPANY Simsbury, Connecticut 06089 Policyholder: (Participating Organization) Policy No.: Certificate No.: (Leave Blank) AGP-5697

More information

Metropolitan Life Insurance Company Statement of Health Form

Metropolitan Life Insurance Company Statement of Health Form Metropolitan Life Insurance Company Statement of Health Form Instructions for Completing Statement of Health Form A separate Statement of Health form is required for each Proposed Insured requesting insurance.

More information

Ohio Public Employees Retirement System 277 East Town Street, Columbus, Ohio 43215-4642 1-800-222-PERS (7377) www.opers.org

Ohio Public Employees Retirement System 277 East Town Street, Columbus, Ohio 43215-4642 1-800-222-PERS (7377) www.opers.org Ohio Public Employees Retirement System 277 East Town Street, Columbus, Ohio 43215-4642 1-800-222-PERS (7377) www.opers.org Disability Benefit Application Important: Please note Managed Medical Review

More information

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form

A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form A Guide for Successfully Completing the Group Life Insurance Evidence of Insurability Form Mutual of Omaha appreciates the opportunity to provide you with valuable life insurance protection for yourself

More information

INSTRUCTIONS FOR PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE [R.C. 3793.31-3793.39] PLEASE READ VERY CAREFULLY!!

INSTRUCTIONS FOR PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE [R.C. 3793.31-3793.39] PLEASE READ VERY CAREFULLY!! INSTRUCTIONS FOR PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE [RC 379331-379339] PLEASE READ VERY CAREFULLY!! ***The employees of Probate Court are unable to provide assistance filling

More information

Frequently Asked Questions (FAQ) Phoenix House New York

Frequently Asked Questions (FAQ) Phoenix House New York About What is? Phoenix House is a nationally recognized and accredited behavioral healthcare provider, specializing in the treatment and prevention of substance use disorders and co-occurring substance

More information

Athletic Trainer License Application Methods

Athletic Trainer License Application Methods Athletic Trainer License Application Methods Please read carefully to determine the application method for which you are qualified Indicate the appropriate method on the application and submit the required

More information

Illinois Standard Health Employee Application for Small Employers

Illinois Standard Health Employee Application for Small Employers INSURER USE ONLY Policy/Group No. Section No. Effective Date New Hire Waiting Period For assistance in completing this application, please contact your employer or insurance agent. For information about

More information

NACCAS Rules of Practice & Procedure January 2014 RULES

NACCAS Rules of Practice & Procedure January 2014 RULES RULES Part 1 Eligibility For Accreditation, The Accreditation Process, Instructions For Submitting Documents To NACCAS; Definitions Sub-Part A Definitions Section 1.0 (e) (f) (g) (h) Definitions The term

More information

Health Care Documents - What You Need to Know

Health Care Documents - What You Need to Know INFORMATION CONCERNING THE MEDICAL POWER OF ATTORNEY THIS IS AN IMPORTANT LEGAL DOCUMENT. BEFORE SIGNING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS: Except to the extent you state otherwise,

More information

Voluntary Benefits Employee Enrollment and Change Form

Voluntary Benefits Employee Enrollment and Change Form LifeMap Assurance Company TM P.O. Box 1271, MS E-3A Portland, OR 97207-1271 (503) 721-7161 (800) 794-5390 Voluntary Benefits Employee Enrollment and Change Form For residents of Oregon and Washington,

More information

Alabama State Board of Pharmacy 111 Village Street. Birmingham, AL 35242 www.albop.com APPLICATION FOR PHARMACIST LICENSURE EXAMINATION

Alabama State Board of Pharmacy 111 Village Street. Birmingham, AL 35242 www.albop.com APPLICATION FOR PHARMACIST LICENSURE EXAMINATION Alabama State Board of Pharmacy 111 Village Street. Birmingham, AL 35242 www.albop.com APPLICATION FOR PHARMACIST LICENSURE EXAMINATION 1, (First) (Middle/Maiden) (Last) of (Street) (City) (County) (State)

More information

Voluntary Benefits Employee Enrollment and Change Form

Voluntary Benefits Employee Enrollment and Change Form Voluntary Benefits Employee Enrollment and Change Form LifeMap Assurance Company TM For residents of Oregon and Washington, the definition of a Spouse includes your legal husband or wife or your State

More information

AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224

AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224 AMERICAN HERITAGE LIFE INSURANCE COMPANY (AHL) 1776 AMERICAN HERITAGE LIFE DRIVE JACKSONVILLE, FLORIDA 32224 For AHL Home Office use only tes EVIDENCE OF INSURABILITY AND ENROLLMENT FORM Check appropriate

More information

PRACTICAL NURSING PROGRAM

PRACTICAL NURSING PROGRAM PRACTICAL NURSING PROGRAM 0 Santa Barbara Blvd. North 3800 Michigan Avenue Cape Coral, FL 33993 Fort Myers, FL 33916 239-574-4440 239-334-4544 www.capecoraltech.edu www.fortmyerstech.edu PROGRAM INFORMATION

More information

COST. CONTACT NEMCC Office of Continuing Education (662) 720-7296

COST. CONTACT NEMCC Office of Continuing Education (662) 720-7296 Certified Nursing Assistant Training Program Class Information Spring 2016 (Keep for your records) CLASS SCHEDULE TBA --- Booneville - Monday & Thursday nights (5:30-9:30) February 11, 2016 --- Corinth

More information

Application for Admission (Supplement Material Packet)

Application for Admission (Supplement Material Packet) Application for Admission (Supplement Material Packet) WELCOME Dear Applicant, Thank you for your interest in Year Up Professional Training Corps (PTC) National Capital Region (NCR) at Woodbridge! Please

More information

REGISTRATION FORMS. Child s Full Name: Birth Date: / / Boy Girl. Child s Full Name: Birth Date: / / Boy Girl

REGISTRATION FORMS. Child s Full Name: Birth Date: / / Boy Girl. Child s Full Name: Birth Date: / / Boy Girl REGISTRATION FORMS Child s Full Name: Birth Date: / / Boy Girl Child s Full Name: Birth Date: / / Boy Girl Child s Full Name: Birth Date: / / Boy Girl Address: City: State: Zip Code: Child #1 Days of the

More information

APPLICATION INSTRUCTIONS FOR LICENSED ALCOHOL AND DRUG ABUSE COUNSELOR (LADAC)

APPLICATION INSTRUCTIONS FOR LICENSED ALCOHOL AND DRUG ABUSE COUNSELOR (LADAC) New Mexico Regulation and Licensing Department BOARDS AND COMMISSIONS DIVISION Counseling and Therapy Practice Board PO Box 25101 Santa Fe, New Mexico 87505 (505) 476-4610 Fax (505) 476-4645 www.rld.state.nm.us

More information

ADDENDUM TO PAGES: 12-14 REVISED

ADDENDUM TO PAGES: 12-14 REVISED ADDENDUM TO PAGES: 12-14 REVISED - 7.1.13 ADMISSIONS TITLE IV FUNDED PROGRAMS NON-TITLE IV FUNDED PROGRAMS CREDIT FOR PREVIOUS EDUCATION / TRAINING RE-ENTRY POLICY CHANGE OF PROGRAM POLICY REQUESTING TRANSCRIPTS

More information

City College of New York Residency Checklist

City College of New York Residency Checklist City College of New York Residency Checklist All Students must complete the CUNY Residency Form with the appropriate documentation. Please choose one of the following if applicable: If you are Undocumented

More information

INSTRUCTIONS FOR PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE [R.C. 3793.31-3793.39] PLEASE READ VERY CAREFULLY!!

INSTRUCTIONS FOR PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE [R.C. 3793.31-3793.39] PLEASE READ VERY CAREFULLY!! INSTRUCTIONS FOR PETITION FOR INVOLUNTARY TREATMENT FOR ALCOHOL AND OTHER DRUG ABUSE [R.C. 3793.31-3793.39] PLEASE READ VERY CAREFULLY!! ***The employees of Probate Court are unable to provide assistance

More information

Surgical Technician Program Application

Surgical Technician Program Application Contra Costa Medical Career College 4051 Lone Tree Way, Suite C Antioch Ca 94531 Phone (925) 757-2900 Fax( 925) 757-5873 Surgical Technician Program Application Date Name (First, MI, Last) Address City,

More information

APPLICATION FOR DUI COURT

APPLICATION FOR DUI COURT IN THE COURT OF COMMON PLEAS OF CENTRE COUNTY, PENNSYLVANIA COMMONWEALTH OF PENNSYLVANIA OTN # v CP-14-CR- - (name of applicant) APPLICATION FOR DUI COURT the District Attorney of Centre County I,, defendant

More information

Health Link Services Nurse Aide Training Program #3950636 2921 East State Street, Hermitage, PA 16148 Phone: 724.981.7888 Ext. 103 Fax: 724.981.

Health Link Services Nurse Aide Training Program #3950636 2921 East State Street, Hermitage, PA 16148 Phone: 724.981.7888 Ext. 103 Fax: 724.981. Health Link Services Nurse Aide Training Program #3950636 2921 East State Street, Hermitage, PA 16148 Phone: 724.981.7888 Ext. 103 Fax: 724.981.9218 APPLICATION The Nurse Aide Training Program does not

More information

How To Complete The Kcdcoastal Health Cooperative'S Authorization To Disclose Protected Health Information Form

How To Complete The Kcdcoastal Health Cooperative'S Authorization To Disclose Protected Health Information Form Authorization to Use and Disclose Protected Health Information Form Under the HIPAA Privacy Rule, an individual may authorize the release of his or her protected health information (PHI) to a specific

More information

APPLICATION FOR DOMESTIC RECIPROCITY LICENSE. The State Board of Cosmetology may grant license by reciprocity, without examination, if:

APPLICATION FOR DOMESTIC RECIPROCITY LICENSE. The State Board of Cosmetology may grant license by reciprocity, without examination, if: 2401 NW 23rd Street, Suite 84 Reciprocity Department 405.522.7620 Fax 405.521.2440 MARY FALLIN GOVERNOR SHERRY G. LEWELLING EXECUTIVE DIRECTOR APPLICATION FOR DOMESTIC RECIPROCITY LICENSE The State Board

More information

PHASE II CHEMICAL DEPENDENCY COUNSELOR ASSISTANT APPLICATION

PHASE II CHEMICAL DEPENDENCY COUNSELOR ASSISTANT APPLICATION PHASE II CHEMICAL DEPENDENCY COUNSELOR ASSISTANT APPLICATION This application must be returned to the Ohio Chemical Dependency Professionals Board. It will not be considered complete until all related

More information

TRANSFER APPLICATION FOR GEORGIA CERTIFICATION Georgia Certified Alcohol and Drug Counselor Levels I, II and III

TRANSFER APPLICATION FOR GEORGIA CERTIFICATION Georgia Certified Alcohol and Drug Counselor Levels I, II and III Alcohol & Drug Abuse Certification Board of Georgia 6755 Peachtree Industrial Boulevard #110 Atlanta, GA 30360 (770) 825-0481 FAX (770) 825-8157 www.adacbga.org TRANSFER APPLICATION FOR GEORGIA CERTIFICATION

More information

APPLICATION TO AMEND CERTIFICATE OF BIRTH

APPLICATION TO AMEND CERTIFICATE OF BIRTH APPLICATION TO AMEND CERTIFICATE OF BIRTH STATE OF LOUISIANA DHH/OPH/Vital Records Packet 18, Rev 08/04 Applicant s Name: Last First Middle Street Address: City: Tel No State: Zip Code: Signature: Relationship

More information

**Make check or money order payable to the Montana Board of Barbers and Cosmetologists**

**Make check or money order payable to the Montana Board of Barbers and Cosmetologists** Page 1 of 5 MONTANA BOARD OF BARBERS AND COSMETOLOGISTS P. O. Box 200513 301 S PARK, 4 TH FLOOR (Delivery) Helena, Montana 59620-0513 (406) 841-2202 FAX (406) 841-2309 E-MAIL: dlibsdcos@mt.gov WEBSITE:

More information

Optima Health Plan and Optima Health Insurance Company Enrollment Application and Waiver 51-99 Coordination of Benefits

Optima Health Plan and Optima Health Insurance Company Enrollment Application and Waiver 51-99 Coordination of Benefits 4417 Corporation Lane Virginia Beach, VA 23462 Subscriber #: Date: FOR PLAN USE ONLY Optima Health Plan and Optima Health Insurance Company Enrollment Application and Waiver 51-99 Coordination of Benefits

More information

GENERAL INFORMATION/INSTRUCTIONS. Application for Chiropractic Acupuncture Certification

GENERAL INFORMATION/INSTRUCTIONS. Application for Chiropractic Acupuncture Certification Department of Health Board of Chiropractic Medicine 4052 Bald Cypress Way, Bin #C07 Tallahassee, FL 32399-3257 GENERAL INFORMATION/INSTRUCTIONS Application for Chiropractic Acupuncture Certification HOW

More information

Pearl River Community College Nursing Assistant Program 5448 U.S. Hwy 49 South Hattiesburg, MS 39401

Pearl River Community College Nursing Assistant Program 5448 U.S. Hwy 49 South Hattiesburg, MS 39401 Pearl River Community College Nursing Assistant Program 5448 U.S. Hwy 49 South Hattiesburg, MS 39401 Instructor: Mrs. T. Camille Killough, RN, BSN Phone: 601-554-5537 Thank you for your interest in the

More information

Professional Nursing Program LPN to RN Bridge Track

Professional Nursing Program LPN to RN Bridge Track 2014 Admissions Packet for Professional Nursing Program LPN to RN Bridge Track Teterboro Campus 546 U.S. Highway 46 West Teterboro, New Jersey 07608 Tel: 201.489.5836 Jacksonville Campus 8131 Baymeadows

More information

Seven Generations Charter School 154 East Minor Street Emmaus, PA 18049. Board of Trustees. Enrollment Policy

Seven Generations Charter School 154 East Minor Street Emmaus, PA 18049. Board of Trustees. Enrollment Policy Seven Generations Charter School 154 East Minor Street Emmaus, PA 18049 Board of Trustees Purpose The Board of Trustees of Seven Generations Charter School ( Charter School ) recognizes that its enrollment

More information

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit. Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)

More information

Great news! What are the benefits to applying for licensure through the ASPPB PLUS program? SECURE

Great news! What are the benefits to applying for licensure through the ASPPB PLUS program? SECURE Great news! The New Mexico Board of Psychologist Examiners is excited to offer you the opportunity to apply for licensure online via the Association of State and Provincial Psychology Boards (ASPPB) Psychology

More information

FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA

FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE CITY STATE ZIP CITY STATE ZIP COUNTY USA PATIENT S INFORMATION NAME (Last, First, Middle) PREVIOUS LAST NAME NICKNAME SOCIAL SECURITY NUMBER BIRTH SEX MALE FEMALE DRIVER S LICENSE NUMBER STATE ISSUED PLACE OF BIRTH CITY STATE PATIENT S BILLING/MAILING

More information

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY APPLICATION FOR LIMITED LICENSURE DENTIST/DENTAL HYGIENIST

FLORIDA DEPARTMENT OF HEALTH BOARD OF DENTISTRY APPLICATION FOR LIMITED LICENSURE DENTIST/DENTAL HYGIENIST Statute and Rule References: -Section 456.015, Florida Statutes -Rule 64B5-7.007, Florida Administrative Code APPLICATION FOR LIMITED LICENSURE DENTIST/DENTAL HYGIENIST General Requirements and Information

More information

How To Become An International Student

How To Become An International Student 1926 West 17th St - Santa Ana, CA 92706 - Tel (714) 835-0278 ESTIMATED EXPENSES Estimated School Costs and Living Expenses for International Students All fees subject to change without notice COSMETOLOGY

More information

CALIFORNIA WOMEN FOR AGRICULTURE SCHOLARSHIP PROGRAM

CALIFORNIA WOMEN FOR AGRICULTURE SCHOLARSHIP PROGRAM CALIFORNIA WOMEN FOR AGRICULTURE SCHOLARSHIP PROGRAM February 2016 In our continuing commitment to promote awareness and education, the Salinas Valley Chapter of California Women for Agriculture (CWA)

More information

Ambassador Application

Ambassador Application Ambassador Application Dear Applicant, Thank you for your interest in Dallas Medical Center s Ambassador Program! Your willingness to invest a few hours each week is greatly appreciated. I believe you

More information

2014-2016 TVCC/OCNE NURSING PROGRAM APPLICATION PACKET DIRECTIONS

2014-2016 TVCC/OCNE NURSING PROGRAM APPLICATION PACKET DIRECTIONS 2014-2016 TVCC/OCNE NURSING PROGRAM APPLICATION PACKET DIRECTIONS Thank you for your interest in Treasure Valley Community College (TVCC) Nursing Program. TVCC s nursing program is a member of the Oregon

More information

Revelation School of Florida Home School Program Florida Statue 1002.41.

Revelation School of Florida Home School Program Florida Statue 1002.41. Revelation School of Florida Home School Program Florida Statue 1002.41. 10658 S.W. 186 Street Miami, Fl. 33157 (305) 786-343-1277 Fax (305) 969-9748 www.revelation320.com Check List for High School Required

More information

11 LC 36 1936S A BILL TO BE ENTITLED AN ACT

11 LC 36 1936S A BILL TO BE ENTITLED AN ACT The Senate Regulated Industries and Utilities Committee offered the following substitute to HB 374: A BILL TO BE ENTITLED AN ACT 1 2 3 4 5 6 7 8 9 To amend Chapter 10 of Title 43 of the Official Code of

More information

Pierpont Community & Technical College School of Health Careers Practical Nursing Program

Pierpont Community & Technical College School of Health Careers Practical Nursing Program Pierpont Community & Technical College School of Health Careers Practical Nursing Program ADMISSION PROCESS 1. Complete and submit Pierpont Community & Technical College application including: a. Submit

More information

GROUP DISABILITY INCOME INSURANCE ENROLLMENT

GROUP DISABILITY INCOME INSURANCE ENROLLMENT GROUP DISABILITY INCOME INSURANCE ENROLLMENT Policy Number 01-016542-00 TO BE COMPLETED BY THE POLICYHOLDER Employer/Policyholder Name School Board of Okaloosa County Symetra Life Insurance Company 777

More information

Stonebridge Adult Medicine, P.A. Registration Form (Please Print)

Stonebridge Adult Medicine, P.A. Registration Form (Please Print) Stonebridge Adult Medicine, P.A. Registration Form (Please Print) PATIENT INFORMATION Last Name: First Name: Is this your legal name? Yes No If not what is your legal name: Date of Birth: Sex: male female

More information

Admission Policy for Post-Secondary/Practical Nursing Program. Application for Post-Secondary/Practical Nursing Program

Admission Policy for Post-Secondary/Practical Nursing Program. Application for Post-Secondary/Practical Nursing Program Admission Policy for Post-Secondary/Practical Nursing Program Application for Post-Secondary/Practical Nursing Program Montachusett Regional Vocational Technical School ADMISSION POLICY Post-Secondary/Practical

More information

Name Change. Introduction. How do I get a court-ordered name change? How do I change my name at marriage and divorce?

Name Change. Introduction. How do I get a court-ordered name change? How do I change my name at marriage and divorce? Name Change Introduction In Washington State, if you are over eighteen years of age, you can choose and use any name you wish, as long as you are not trying to defraud someone. Example: it is not legal

More information

STATE OF IOWA IOWA DENTAL BOARD

STATE OF IOWA IOWA DENTAL BOARD STATE OF IOWA IOWA DENTAL BOARD TERRY E. BRANSTAD, GOVERNOR KIM REYNOLDS, LT. GOVERNOR JILL STUECKER EXECUTIVE DIRECTOR Dental Assistant Trainee Application Application Form and Fee Please find enclosed

More information

WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?

WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called? Today s Date: / / WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT Full Name: What would you prefer to be called? Street Address (If P. O. Box, provide street address

More information

STEP 2: Please complete the Special Needs and Circumstances Section. STEP 3: Please take a moment to complete our questionnaire.

STEP 2: Please complete the Special Needs and Circumstances Section. STEP 3: Please take a moment to complete our questionnaire. New Rising Star Missionary Baptist Church Rising Stars Enrichment Program Registration Packet 7400 London Avenue, Eastlake Birmingham, Alabama 35206 Phone: (205) 833-3676 Email Address: risingstarscamp@nrschurch.org

More information

FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST

FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST Department of Public Safety - Technology 11400 Greenstone Avenue Santa Fe Springs California 90670 Tracy Rickman, Academy Coordinator (562) 941-4082 Class FIREFIGHTER I ACADEMY APPLICATION & CHECKLIST

More information

INSTRUCTION SHEET PHARMACY TECHNICIAN

INSTRUCTION SHEET PHARMACY TECHNICIAN INSTRUCTION SHEET PHARMACY TECHNICIAN An applicant for registration as a pharmacy technician may assist a registered pharmacist in the practice of pharmacy for a period of up to 60 days prior to the issuance

More information

State of Utah DEPARTMENT OF COMMERCE DIVISION OF CONSUMER PROTECTION

State of Utah DEPARTMENT OF COMMERCE DIVISION OF CONSUMER PROTECTION State of Utah DEPARTMENT OF COMMERCE DIVISION OF CONSUMER PROTECTION CERTIFICATE OF POSTSECONDARY STATE AUTHORIZATION: PUBLIC NONPROFIT POSTSECONDARY SCHOOL APPLICATION (continuous operation for at least

More information

APPLICATION FOR EMPLOYMENT FOR DEPUTY ATTORNEYS GENERAL

APPLICATION FOR EMPLOYMENT FOR DEPUTY ATTORNEYS GENERAL State of New Jersey Department of Law and Public Safety Division of Criminal Justice APPLICATION FOR EMPLOYMENT FOR DEPUTY ATTORNEYS GENERAL The State of New Jersey is an Equal Opportunity Employer APPLICATION

More information

DAUPHIN COUNTY TECHNICAL SCHOOL 6001 Locust Lane Harrisburg, PA 17109 www.dcts.org Phone: (717) 652-3170, Guidance ext. 7432

DAUPHIN COUNTY TECHNICAL SCHOOL 6001 Locust Lane Harrisburg, PA 17109 www.dcts.org Phone: (717) 652-3170, Guidance ext. 7432 DAUPHIN COUNTY TECHNICAL SCHOOL 6001 Locust Lane Harrisburg, PA 17109 www.dcts.org Phone: (717) 652-3170, Guidance ext. 7432 Middle School Application for 9 th Grade Acceptance 2016-2017 Please Print Clearly

More information

Practical Nursing Process & Application Documentation

Practical Nursing Process & Application Documentation Medical Professional Institute 380 Pleasant Street Malden, MA 02148 (781) 397-6822 Practical Nursing Process & Application Documentation Thank you for your interest in pursuing an education through Medical

More information