ENROLLMENT APPLICATION

4089 Val Tech Road * Building 100, Room 132 * Valdosta, Georgia 31602 * 866-938-3098 F 866-680-1738
ENROLLMENT APPLICATION
PLEASE COMPLETE THIS FORM IN DETAIL. PLEASE PRINT.
Select Campus*
1. Full Name (First & Middle, Last) (As shown on your Social Security card / Government ID)*

Last NameFirst Name
2.Date of Birth (MM/DD/YYYY)*

MonthDayYear
Date
3.If any of your records are under a name other than the one given above (i.e., maiden name), please list the name(s) below: (last, first, middle)
4.Social Security #
5. Email Address*
example@example.com
6. Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
6. Current Address (If different from permanent address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
7. Telephone: (Home) (Work) (Other)*
Format: (000) 000-0000.
8. Are you a US Citizen*

YesNo
Emergency Contact Information
1. Name*
2. Relationship*
3. Phone #*
Format: (000) 000-0000.
4. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Enrollment Information
1a. Select Desired Start Year
1b. Select Desired Start Month
2. Do you have a Class II Medical Certificate

YesNo
(If yes, please include a copy with this application)
File Upload

Cancelof
7.Do you have any past air traffic control or aviation experience?

YesNo
If yes, please provide more information below
8. Are you registered with the selective service?

YesNo
9.Have you ever been convicted of, pled guilty to, or have been charged of a crime other than a traffic offense?

YesNo
If yes, please date and explain any offenses
10. Have you ever tested positive for drugs/controlled substances?

YesNo
In the event that your telephone number is registered on the National Do Not Call Registry, the signature below gives consent for Advanced ATC, Inc. to call you for 18 months or until the designated time of your class start, whichever comes later. All information provided on this application is true and complete to the best of my knowledge. I understand that admission to the college is contingent upon submission of high school graduation or attainment of a GED prior to matriculation, satisfaction of all admission criteria, my acceptance by the college, my signing of the college’s Enrollment Agreement, and the college’s acceptance of the Enrollment Agreement.

I authorize the college to request and receive a copy of my high school and/or college transcripts, including GED certificate.
Signature of Applicant
Date

MonthDayYear
Date
Wiregrass Georgia Technical College/Advanced ATC, Inc. does not discriminate on the basis of race, color, religion, national origin, ancestry, sex, age, sexual orientation or disability in the administration of any of its educational programs or activities or with respect to admissions or employment.

Please click submit below (be sure to print a copy for your records)
Should be Empty:

4089 Val Tech Road * Building 100, Room 132 * Valdosta, Georgia 31602 * 866-938-3098 F 866-680-1738

ENROLLMENT APPLICATION

Emergency Contact Information

Enrollment Information