Technician Certificate Program Application FormPrint this form, complete it, and send it to:
Select the program you want: (circle only one for each application form)
APPLICANT:
NAME _______________________________________________________________________ Title ________________________________________________________________________ EMPLOYER
___________________________________________________________________ MAILING
ADDRESS _____________________________________________________________ CITY ______________________________________
STATE _________ ZIP ______________ BUSINESS
PHONE ______________________________________________________________ BUSINESS
FAX ________________________________________________________________ EMAIL ADDRESS
_______________________________________________________________
EDUCATION: SCHOOL(S)
ATTENDED: ________________________________________________________ DIPLOMA:___YES
____NO GED:____YES ____NO DATE RECEIVED:
__________________
COLLEGE: INSTITUTION
ATTENDED: _______________________________________________________ DATES ATTENDED:
_____________________________________________________________ DEGREE RECEIVED:
_____________________________________________________________ INSTITUTION
ATTENDED: ________________________________________________________ DATES ATTENDED:
______________________________________________________________ DEGREE RECEIVED:
______________________________________________________________
OTHER EDUCATION: (e.g.: Military Training, Professional Courses)
EXPERIENCE HISTORY: EMPLOYER:
___________________________________________________________________ ADDRESS:
____________________________________________________________________ CITY: _______________________________________
STATE ______ ZIP________________ DATES EMPLOYED:
____________________________________________________________ RESPONSIBILITIES:
____________________________________________________________ EMPLOYER:
___________________________________________________________________ ADDRESS:
____________________________________________________________________ CITY: _______________________________________
STATE ______ ZIP________________ DATES EMPLOYED:
____________________________________________________________ RESPONSIBILITIES:
____________________________________________________________ EMPLOYER:
___________________________________________________________________ ADDRESS:
____________________________________________________________________ CITY: _______________________________________
STATE ______ ZIP________________ DATES EMPLOYED:
____________________________________________________________ RESPONSIBILITIES:
____________________________________________________________ EMPLOYER:
___________________________________________________________________ ADDRESS:
____________________________________________________________________ CITY: _______________________________________
STATE ______ ZIP________________ DATES EMPLOYED:
____________________________________________________________ RESPONSIBILITIES:
____________________________________________________________ Please add additional sheets if necessary.
SUPERVISOR: NAME: ______________________________________________________________________ TITLE: ______________________________________________________________________ EMPLOYER:
_____________________________________ STATE ______ ZIP ____________ ADDRESS:
___________________________________________________________________ ____________________________________________________________________________ BUSINESS
PHONE: ___________________________ BUSINESS
FAX: _____________________________ As the Supervisor
of __________________________, I approve and support his/her participation
in the _________________ Technician Certificate Program. _____________________________
_________________________________ _______________ APPLICATION
FEE: $75.00 (This is non-refundable.) Check enclosed (payable to UNC-CH) _____ Please charge to: _____ Mastercard _____VISA _____ Diners Club PLEASE PRINT
NAME ON CARD________________________________ _______________________________/___________
SIGNATURE:_________________________________ ___________________________________________ One of the above forms of payment above must accompany your application form. Mail
to: North Carolina Education and Research Center Phone: (919)962-2101
or (888)235-3320 |