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Midwest Diesel Tech Academy
APPLICATION FOR ENROLLMENT
PERSONAL INFORMATION
Please enter your name as it appears on your driver's license.
LEGAL NAME:
Last:
First:
Middle:
Date of Birth and Social Security Number are required during enrollment.
E-mail Address:
PERMANENT ADDRESS:
Street Address:
Apt#:
City:
State:
Zip:
Cell Phone:
Alt. Phone:
Do you have a valid driver's license?
Yes
No
CDL?
Yes
No
Class:
Endorsements:
Do you have reliable transportation to the academy and work?
Yes
No
EDUCATION:
High School Name:
City/State:
Years Attended:
Date Graduated:
Copy of High School transcript is required at interview.
Name of College Attended:
City/State:
Years Attended:
Date Graduated:
DETAILS OF EMPLOYMENT
Dates:
Name of Company:
Duties:
Dates:
Name of Company:
Duties:
CAREER OBJECTIVE
What are your plans/goals upon completion of this program?
Please describe in 200 words or less why you should be accepted to attend the Midwest Diesel Tech Academy, LLC.
I acknowledge this is an electronic signature and in result will be considered a signature to authorize the above application.
Signature: