WEST TN A&M REGISTRATION FORM

WEST TN A&M REGISTRATION FORM

Western Tennessee A&M | School of Engineering & Design
Which Semester are you enrolling in?*

Summer 2025 (Classes begins June 2025)
What Training are you interested in;*

Telecommunication (Fiber Optic) Technician ApprenticeshipHVAC Technician ApprenticeshipPlumbing Technician ApprenticeshipElectrical Technician ApprenticeshipCybersecurity / Comp TIA Security +Paralegal/Legal AssistantBusiness Development CohortSolar Technician
Do you want to apply for a scholarship for tuition?*

YesNo
Do you live in Memphis?*

YesNo
Employment Status*

employed full-timepart-time,unemployed
If No, What City and State
Education Level*

I'm in 10th gradeI'm in 11th gradeI'm in 12th gradeI am a High School GraduateI am a GED RecipientCollege DegreeGraduate Degree
YOUR INFORMATION
Name*

First NameLast Name
Take Photo*
Race*

BlackWhiteAsainHispanicOther
Gender*

MaleFemale
Date of Birth*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell*

Area CodePhone Number
Home*

Area CodePhone Number
EMERGENCY CONTACT
Name*

First NameLast Name
Relationship to student*
Phone Number*

Area CodePhone Number
Email
example@example.com
Check Box to Confirm*

I confirm the selected program and acknowledge understanding of information aboce.
Should be Empty:

YOUR INFORMATION