Student Information Your name Your email Phone Address City State Zip Code Class You Are Interested in Attending June 2024August 2024 Are You Familiar With the Zoom App? YesNo Education and Training High SchoolGEDCollegeVocational School Course of Study Highest Degree Received (if applicable) References List three personal references – do not include relatives or employers. Name Occupation Phone Name Occupation Phone Name Occupation Phone Background Information Have you ever been convicted of, placed on probation for, or received deferred adjudication for a felony or misdemeanor, or are you currently awaiting trial for, on probation or deferred adjudication for, a felony or misdemeanor? YesNo If yes, please identify the crime for which you were convicted or given deferred adjudication, the date of the conviction / deferred adjudication and the location of the court. Convictions will not necessarily disqualify an applicant. All facts and circumstances will be considered. Authorization I understand that the Program will verify all data provided in my application. I authorize such investigation and the giving and receiving of any information requested by the Program. I release from liability any person giving or receiving such information. I understand this entire application must be completed. Omission of information or failure to submit required documents may invalidate this application from further consideration for enrollment, or if enrolled, may subject me to immediate dismissal. I understand that this application is not a contract between me and Southeast Texas Phlebotomy Institute and that there is no real or implied warranty. Yes, I Consent Todays Date Please answer the following questions in the space provided below. Why does the Program you chose interest you, and how were you referred? (Internet, friend, newspaper, etc.) What qualities or experiences make you an ideal candidate for the program? (Be specific.) What are your long term professional and personal goals? Comments or Questions (optional) Please prove you are human by selecting the star.
