EmailMe Form - SITTI, LLC

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EmailMeForm

Name
First Last
Email
Social Security Number
Phone
### - ### - ####
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Emergency Contact
Name
First Last
Relationship
Phone
### - ### - ####
Email
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Universities that are recipients of federal dollars are required by the Federal government to solicit certain demographic information to meet federal reporting requirements. Applications are requested to provide the following information voluntarily. This information will not be utilized in a discriminatory manner.
Nation of Citizenship
Race / National Origin
Native Language
Religion
Gender
Male
Female
Are you a veteran of the U.S. Military?
Yes
No
Date of Birth
MM / DD / YYYY
Select the program you are enrolling in: *
**Full tuition must be paid FIRST DAY of CLASS.**
Select to pay Seat Registration Fee or Full Tuition: *
**Full tuition must be paid FIRST DAY of CLASS.**
For which term do you seek admission?
Select two preferred locations for hands-on training *
Please indicate your preference learning environment:
On-campus
On-line
Hybrid
Are you currently or have you ever been charged with or subject to disciplinary action for scholastic or any other type of misconduct at any educational institution?
Yes
No
If yes, please explain.
High School Information
High School Name
6 Digit High School CEEB Code
Graduation Date
MM / DD / YYYY
Or enter year of GED
Where did you hear about this training opportunity:
Current (not expired) Government Issue Identification Card
Social Security Card
Copy of High School Diploma/GED (if not you must take the entrance exam)
Select a healthcare experience
Proof of Healthcare Training (current certification) Workshop Applicants
I certify that my answers are true and I am solely responsible for paying Selma Innovation Technology Training Institute, LLC for the Tuition of training program upon schedule due date; if I am late a 9% interest will be applied. I do understand this ONLY cover the cost of training.
(By Enter my Name & Date) in the box below as electronic signature)

Emergency Contact

High School Information