MERIT TRAINING INSTITUTE
Student Application
First Name
*
Last Name
*
Nickname or Preferred Name
Address
*
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Cell Number
*
Do we have permission to text this number?
Please Select
Yes, you can text me!
No, please no text.
Social Security Number
*
Email Address
*
example@example.com
Alternate Email Address
example@example.com
Birth Date
*
/
Month
/
Day
Year
Date
Emergency Contact
Emergency Contact Relationship
Emergency Contact Phone Number
Format: (000) 000-0000.
Do you have a High School Diploma or GED?
*
No
Yes
If yes, which?
How did you hear about Merit Training Institute?
CareerBuilder
Job Fair
Word-of-mouth (please list below):
Craigslist
One-Stop/Counselor
Facebook
Other (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.
Word
Access
PowerPoint
QuickBooks
Excel
Outlook
Epic
Other (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
Format: (000) 000-0000.
Signature
*
Date
*
-
Month
-
Day
Year
Date
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