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Important Note: All LPN applications must be picked up in person at the Main Campus in Elizabethton. Applications for the LPN classes are only available on a first-come, first-serve basis.

Please provide the following information. Fields with a * are required.

Contact Information:

First Name*

Last Name*

Middle Name

Street Address*

Address (cont.)

City*

State/Province*

Zip/Postal Code*

Work Phone

Home Phone

E-mail

Personal Information*
Gender:	MaleFemale
Veteran:	Yes No
Single Parent:	Yes No N/A
Limited English Proficient:	Yes No
Displaced Homemaker:	Yes No N/A

*Race:

Educational Background:

Education (highest level completed)
High School Attended
Last School Attended
Year of High School Graduation(YYYY)

Registration Information:

* Program(s) of Interest (choose at least one):
Automotive Technology		Business Systems Technology
Diesel Mechanics		Computer Information Technology
Dietary Manager		Electricity & Electronics
Practical Nursing		HVAC & Refrigeration
Certified Nursing Assistant (CNA)		Welding
Millwright Skills		Other:

Date you desire to enroll:

Do you plan to apply for financial aid? Yes No
Benefits Expected: GI Bill VA Rehab War Orphan Voc. Rehab	WIA Pell Lottery
Scholarship(Please Name):
Other(Please State):

Additional Information:

Are you presently incarcerated? (If incarcerated, you cannot receive financial assistance.)	Yes No
Have you ever attended this school before?	Yes No
If yes, please state the year:
Do you have any disabilities that require special accommodations to start your training?	Yes No
If yes, explain:

Where did you hear about Elizabethton Technology Center?	Newspaper Radio Friend Counselor Student Web Site Other
	If other, please specify

Auxiliary aids and services for individuals with disabilities and/or limited English proficiency are available upon request to the Student Services Coordinator. Telephone (423) 543-0070. TDD: (423) 547-7511 or (423) 610-0134.

Comments or inquiry:

The above information is used for reporting purposes only. The Tennessee Technology Center at Elizabethton does not discriminate on the basis of race, color, national origin, religion, or sex.

AN EEO/AA/ADA Employer/Institution