SWITCHBOARD

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Program of Study *

DAY CLASSES PREFERRED EVENING CLASSES PREFERRED

Start Date *

Last Name

First Name

Middle Name

Suffix (Jr, Sr, III)

Preferred First Name

Do you have HS Diploma or GED?

Yes No

OTHER NAMES UNDER WHICH YOUR RECORDS MAY APPEAR:

Other Name 1

Other Name 2

Other Name 3

Maiden Name

STUDENT INFORMATION:

U.S. Social Security Number

Birth Date

Marital Status

Gender

Male Female

STUDENT PERMANENT HOME ADDRESS:

Number Street Name

City

State

Zip Code

Country

MAILING ADDRESS FOR REPLY:

Check here if same as above

Number Street Name

City

State

Zip Code

Country

PHONE NUMBER AND E-MAIL ADDRESS:

Home Telephone

Cell Phone

Work Phone

Email Address

EMERGENCY CONTACT INFORMATION:

Last Name

First Name

Middle Name

Phone

Last Name

First Name

Middle Name

Phone

CITIZENSHIP INFORMATION: Please check the appropriate box

CITIZENSHIP

U.S. Citizen U.S. Permanent Resident Non-U.S. Citizen

Country of Birth

Country of Citizenship (if not U.S.)

RESIDENT STATUS:

TX Resident

Yes No

Years

Months

Non-Resident

ETHNICITY:

Ethnicity

Hispanic of any race Non-Hispanic

RACE INFORMATION: (Race information is voluntary and is requested for reporting purposes only, in accordance with the 1964 Civil Rights Act as amended (U.S.Citizens Only)

What is your race?

U.S. VETERAN INFORMATION

Veteran

Yes No

SELECTIVE SERVICE REGISTRATION

Have you registered with Selective Service?

Yes No Not Applicable – I am not required to register with Selective Service

YOUR EDUCATIONAL LEVEL: You will need to provide copies of your transcripts for all educational institutions you have attended.

Less than high school Currently in high school Certificate of high school completion Official high school diploma

GED passed Some college credits Associates degree Bachelor degree or higher

HIGH SCHOOL INFORMATION:

Not Applicable

Graduation Date

Name of High School

City of High School

State of High School

Graduation Date

Name of High School

City of High School

State of High School

Graduation Date

Name of High School

City of High School

State of High School

COLLEGE INFORMATION:

Not Applicable

Graduation Date

Name of Institution

City of Collage

State of Collage

Graduation Date

Name of Institution

City of Collage

State of Collage

DISCLOSURE: This section is mandatory. Failure to complete fully may either delay your application or affect your enrollment status should you be enrolled

If you answered YES to any of the above questions, please write a description of the circumstances in the box below. No decision will be made on your application until you have provided this information

AFFIRMATION:

I affirm by checking this box that I have furnished all information requested in this application. I understand that submitting any false information to the MT Training Center, including but not limited to: false transcripts, test scores or any information contained on this form, or withholding information about my previous academic history will make my application to the MT Training Center, as well as any future applications, subject to denial and/or expulsion from the school.

Reference Contact Information 1

Last Name

First Name

Address

City

State

Zip

Home Phone

Cell Phone

Relationship to Student

Reference Contact Information 2

Last Name

First Name

Address

City

State

Zip

Home Phone

Cell Phone

Relationship to Student

Reference Contact Information 3

Last Name

First Name

Address

City

State

Zip

Home Phone

Cell Phone

Relationship to Student