LSC-NORTH HARRIS APPLIED TECHNOLOGY APPLICATION

INSTRUCTIONS: Please answer all questions. If a question does not apply to you, please choose "N/A".

PART I

APPLICANT INFORMATION

Name *

Student ID# *

Phone *

Mailing Address *

City *

State *

Postal Code *

Email Address: *

Which Applied Technology program are you applying for? *

EDUCATION

High School *

Address *

From: *

To: *

Degree *

Did you graduate? *

Yes

If GED or High School equivalency, check here

GED

College

Address

From:

To:

Degree

Did you graduate?

Yes

Other

Address

From:

To:

Degree

Did you graduate?

Yes

EMPLOYMENT INFORMATION (FOR THE PAST FIVE YEARS)

Current/Former employer:

Employer address:

How long?

City

State

Zip code:

Position

Former employer:

Employer address:

How long?

City

State

Zip code:

Position

Former employer:

Employer address:

How long?

City

State

Zip code:

Position

Have you ever been convicted of a felony? * 🛈

EMERGENCY CONTACT

Name

Phone

Relationship:

MILITARY SERVICE

Branch

From:

To:

Rank at Discharge:

Type of Discharge:

If other than HONORABLE, please explain:

REFERENCES

Name *

Address *

Phone *

Name *

Address *

Phone *

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to acceptance into the program, I understand that false or misleading information in my application or interview may result in my release.

I agree with the terms and conditions as stated above. *

Yes

Signature of applicant:

ESSAY QUESTION

PART II

A typed “Statement of Intent” is required to enter any Applied Technology program. The applicant should state their experience in the field, if any, and the reason(s) they would like to enter the LSC-NH program. In addition, the applicant should indicate their educational and career goals (250 word maximum, double-spaced, Times Roman font, 12- point, black). *

0/250 words

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