Abcott Institute :: Leaders in IT

Please fill in the following information completely and accurately.

1. Personal Information

Date : - -

Name :

Date of Birth : - -

Address :

City :

State :

Zip :

Email :

Home Phone :

Cell/Alt. Phone :

Additional Phone Number where we may leave a message for you:

Please tell us about you:

Are you working right now? - Yes No
If no, how long have you been unemployed? - Months Years
If yes, how many hours per week do you work? Average hourly income : $ per hour
Are you collecting or have you collected unemployment benefits within the last 12 months? Yes No
If yes, When did you receive your last check? Date : - -
Reason for Unemployement : Laid-off/lack of work/downsize ( Permanent ) Seasonal/temporary lay-off
Terminated
Are you in a Work First Program? No Yes
Are you receiving FIA or other assistance from the state? No Yes
Are you in MRS or receiving disability for yourself? No Yes
Have you recently or are you currently attending school?
If yes, what field of study?
(Check all that apply) Are you: Married Single Separated living with significant other/relative
How many dependents do you have?
Is finding childcare a concern for you if you are accepted for enrollment by Abcott Institute? No Yes
Have you ever been convicted of a crime? No Yes
If yes Please explain :

Note: Convictions do not disqualify you from enrollment at Abcott. Please see your Abcott representative to discuss your specific situation.
Do you have valid identification that proves your residency? No Yes
What is the last grade of school you completed?
Grade High School graduate GED Some college College degree Vocational

List any certificates, licenses, degrees, or diplomas you hold and what year you obtained them:

How did you hear of us? Employment Guide Other publication MI Works Websites TV
Friends or Relatives , Name : Other , Name :

2.What course(s) are you interested in taking?

Medical	Computer
CNA/HHA Phlebotomy Patient Care Technician Medical Assistant Medical Billing & Coding Massage Therapy	Introduction to Computers (IC3) MOS (Microsoft Word, Excel, Powerpoint, and Access) A+ (Computer Repair) Network Administrator (A+, Net+, MCSA, CCNA, CCSA) Network Security (CCSA) Some Other :