Please complete the following information:

Date: ______________


Class you are interested in: ____________________________________________

Name: _______________________________      SSN: ______ - ______ - ______

Address: __________________________________________    ______________
                              Street                                                                                                          Unit #
                ________________________________   _____________  ___________
                                   City                                                                                State                           Zip

Home Phone #: (_____)_____________   Work Phone #: (_____)_____________

Are you a U.S. Citizen? __________   Can you provide proof? __________

Are you a High School Graduate or have a GED? __________

Can you provide a copy of your diploma or equivalency? __________

If not a High School Graduate, highest grade completed: __________

Please list postsecondary schools (colleges, private vocational training, etc.) you
have attended.  Provide name of school and city & state:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Please provide a brief work history:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________
JEM College
CONTACT AND PRELIMINARY INFORMATION
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