Orleans Technical Institute : Admissions

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Admissions Department

(NEW LOCATION)

2770 Red Lion Road

Philadelphia PA 19114

215-728-4700

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The following information is to be filled out by the applicant. If assistance is required, please request help from an admissions representative by calling 215-728-4700.

The information you supply on this form will be shared only with authorized Orleans Technical Institute staff or funding sources. It will NOT be given to any employers, family members, or other unauthorized persons or organizations.

* Indicates a required field.

First Name * Middle Initial Last Name * Address 1 * Address 2 City * State * Zip Code * Home Phone * Work Phone Cell Phone * Email *

Gender * Male Female

Birth Date * Emergency Contact Name *

Citizenship *

Are you a U.S. citizen? Yes No

If foreign, specify country. How many years have you been residing in the U.S.?

Driver's License

Do you have a valid Driver's License * Yes No

If yes, enter Driver's License # *

Veteran's Status * Yes No Currently Enlisted

Preferred Class Time Day Evening

Program Interest Air Conditioning, Refrigeration, and Heating Building Maintenance Carpentry Plumbing and Heating Residential/Commercial Electricity Telecommunications Technician Court Reporting Human Services

Court Reporting Program

Have you ever attended the Court Reporting Program? * Yes No

If so, when

Please list the number of people living in your household, including yourself

Household Language

Is English the primary language spoken in your home? * Yes No

If not, what language is spoken?

How do you plan to finance your transportation to school? * In the event that your transportation finance plan becomes inoperable, how will you get to and from school? *

Work Experience 1 Employer Date of employment from To Salary Position Reason for Leaving

Work Experience 2 Employer Date of employment from To Salary Position Reason for Leaving

Work Experience 3 Employer Date of employment from To Salary Position Reason for Leaving

Please select the total household income that best applies to your household: Under $20,000 $20,001 – $35,000 $35,001 - $50,000 $50,000 - $100,000 Over $100,000

Religion

Please choose your religion Christian Muslim Jewish Other

If Other, please specify

Ethnicity

Do you identify yourself as Hispanic or Latino?

Yes No

Race

I identify myself as (please check one or more categories that you identify with)

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

NOTICE

Orleans Technical Institute does not offer licensing or certification for the trades.

Students at Orleans Technical Institute are admitted, trained, and referred for employment without regard to race, color, creed, sex, national origin, or handicap. Applications are accepted from high school graduates, seniors anticipating graduation, and students beyond the age of compulsory education with demonstrated ability to benefit from training.

Students of the Court Reporting and Human Services Programs must have a high school diploma or GED.

In the event that I am admitted as a student of Orleans Technical Institute, I will conform to the established curriculum, rules, and regulations.

I understand the content of this application. The information I have given is true and accurate to my knowledge. I fully understand that any information found to be false may result in non-enrollment or subsequent termination from the school.

Today's Date:

I have read and agree to the above notice.

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