TechLEAP/WebLEAP
Admissions Application
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Name: |
Home Phone: |
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Street: |
Work Phone: |
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Apt: |
FAX Number: |
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City: |
Email Address: |
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State: |
Zip: |
Emergency Contact Name: |
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SSN: |
Emergency Contact Phone: |
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Please state briefly your interest in Tech LEAP and how it relates to your professional/career goals:
Please list any current computer/technical skills and competencies:
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Skill Area |
Level of Skill (Advanced, Intermediate, Beginning) |
Education If accepted into Tech LEAP, you will be asked to provide transcripts from each school attended.
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Name of School |
Address |
Dates of Attendance |
Degree/Major |
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High School:
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College:
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Graduate School:
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Technical/Trade School:
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References List three individuals (not family members) who know about your work habits and character.
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Name |
Address |
Phone Number |
Relationship |
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Personal Information Internship and future employment at sponsoring companies usually require an extensive background check and possibly a security clearance. Some companies require drug-screening tests. Misrepresentation of credentials or facts can result in our inability to place individuals in internships and/or dismissal from employment.
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Sex (circle one): Male Female Date of Birth: ______/_______/19___ Month Day Year |
Have you ever been convicted of a law violation, including moving traffic violations but excluding offenses committed before your eighteenth birthday which were adjudicated in a Juvenile Court under a youth offender law (circle one)? Yes No |
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Are you a citizen of the United States? Circle one: Yes No |
If yes to the above, list all and explain: |
If no, are you legally eligible for employment in the US, in compliance with Immigration Reform and Control Act (circle one)? Yes No |
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Have you ever held a security clearance? Circle one: Yes No |
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If so, what level and with what agency? |
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Have you ever been denied a security clearance? |
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Race Code (Although this information must be provided to the U.S. Department of Education by Montgomery College, your response is optional.) Circle one: 1. American Indian 3. Asian 5. White Non-Hispanic 2. Black Non-Hispanic 4. Hispanic 6. Undisclosed |
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Residency (Select one)
_____ I have been a Maryland resident [as defined in the Montgomery College Catalog] for at least three months and live in ________________________________ County. _____ I consider Maryland to be my permanent place of abode, where my possessions are maintained and where I intend to remain indefinitely. _____ I am 60 years of age or older. (Applicable to designated tuition waiver for Maryland residents only.) _____ I am a Maryland National Guard member enlisted for at least a 24-month period and submitting proof of such from the adjutant general’s office. (25 percent tuition waiver applicable to designated tuition waiver courses.) |
Employment Record (Begin with Current Position or Most Recent Position)
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Name of Employer: |
Dates: From To |
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Address: |
Phone: ( ) |
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Salary: Start $ End $ |
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Position Held: |
Supervisor’s Name: |
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Description of Responsibilities: |
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Reason for Leaving: |
May we contact? YES NO |
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Name of Employer: |
Dates: From To |
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Address: |
Phone: ( ) |
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Salary: Start $ End $ |
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Position Held: |
Supervisor’s Name: |
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Description of Responsibilities: |
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Reason for Leaving: |
May we contact? YES NO |
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Name of Employer: |
Dates: From To |
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Address: |
Phone: ( ) |
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Salary: Start $ End $ |
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Position Held: |
Supervisor’s Name: |
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Description of Responsibilities: |
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Reason for Leaving: |
May we contact? YES NO |
US Military Service
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Last Service: From To |
Branch |
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Rank at Discharge or Separation |
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Present Status: Draft Classification or Reserve Status: |
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How did you learn about Tech LEAP? _______________________________________________________________________
I hereby certify that all information provided on each page of this application is true and complete. I understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any benefits or employment gained as a result of this application. I consent to references and former employers and education institutions listed being contacted with regard to this application, and to the information being shared with program sponsors as needed.
| Applicant Signature: | Date: |
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Please mail your application to: Montgomery College Information Technology Institute c/o Raymond J.Kimball OR Fax using (240) 567-1893 |
ITI 12-2000