Merit Training Institute Student Application

MERIT TRAINING INSTITUTE

Student Application
First Name*
Last Name*
Nickname or Preferred Name
Address*

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Cell Number*
Do we have permission to text this number?
Social Security Number*
Email Address*
example@example.com
Alternate Email Address
example@example.com
Birth Date*

MonthDayYear
Date
Emergency Contact
Emergency Contact Relationship
Emergency Contact Phone Number
Do you have a High School Diploma or GED?*

NoYes
If yes, which?
How did you hear about Merit Training Institute?

CareerBuilderJob FairWord-of-mouth (please list below):CraigslistOne-Stop/CounselorFacebookOther (please list below):
If Other, which?
Have you completed a degree or certificate program in the past? If so, what program and year?
What course(s) are you interested in?*

(021-QB) QuickBooks Desktop Certified User & MS Office(021-MOS) Microsoft Office Applications(21-BC) Online Medical Office Administration(16-CNA) Certified Nursing Aide/Assistant(CMA-PCT) Medical Assistant & Patient Care Technician with EHR/EMR(021-MAO) Medical Assistant Hybrid
Please mark the programs you have working knowledge of.

WordAccessPowerPointQuickBooksExcelOutlookEpicOther (List Below)
Would you consider your computer skills beginner, intermediate or advanced?
What is your employment background?
What are your minimum salary expectations (per hour) after your course is completed?*
What type (if any) of office experience have you had in the past?
If interested in a medical course, please explain any medical office experience you may have.
Is there anything that would prohibit you from completing the course?
If you are going to receive funding to pay for your program, please complete the following:
Funding County & Program
Counselor or Official's Name
Counselor or Official's Email
Counselor or Official's Phone Number
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MERIT TRAINING INSTITUTE