EmailMe Form - SITTI, LLC

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)