Student Information

LEGAL NAME
	Last Name	First Name	Middle Name	Maiden Name
	Invalid Input	Invalid Input	Invalid Input	Invalid Input

		malefemale
City/State of Birth	Date of Birth (mm/dd/yyyy)	Gender
Invalid Input	Invalid Input	Invalid Input

Address
	Street	City	State	Zip Code
	Invalid Input	Invalid Input	Invalid Input	Invalid Input

Contact
	Primary Phone Number	Secondary Phone Number	eMail Address (*)
	Invalid Input	Invalid Input	Invalid Input

Emergency Contact
Please list someone that the school may contact in case of an emergency: (other than your home phone)


Name	Phone	Relationship
Invalid Input	Invalid Input	Invalid Input

Ethnic Origin (State Requirement): Please choose all that apply

American Indian or Alaskan NativeAsianAfrican AmericanCaucasianHawaiian or Other Pacific IslanderHispanic/Latino

Invalid Input

Citizenship: Please select one

United States
Other immigration status (attach cop of documentation)
Alien lawfully admitted for permanent residency in the Unites States (attach copy of fromt and back of alien registration card)

Invalid Input

Program Choice

Check the program name to register

Previous Education

Please check all that apply.

High School Graduate GED Some College (no degree) Associate Degree Bachelors Degree Other (please list below) Invalid Input	Graduation Date (MM/YYYY)	Pass Date (MM/YYYY)

	Your Major	What School

	Please list other here:

Current Employment

Are you currently employed? yesno
Invalid Input

Invalid Input
Name of the Company

Invalid Input
What is your position

Please mark all of the following that apply, failure to disclose any of the following will result in your dismissal
I have been convicted of a misdemeanor (even if you have had it expunged)
I have been convicted of a felony (even if you have had it expunged)
I have been denied a license in Ohio or another state
I have had my license revoked, suspended in Ohio or another state
required

If you have marked any of the above, please explain
Invalid Input

Financial Aid Information

Do you wish to apply for Financial Aid? yesno Invalid Input

If so, you will need to see the Financial Aid Administrator to review your options such as: Pell Grant, loans, WIA, VA, BVR, payment plan, Visa or Mastercard

Military Service

If male, are you registered with Selective Service yesno Invalid Input

VA Information for anyone who has been in the service


Service Serial #	Date Entered	Date Discharged	VA File #
Invalid Input	Invalid Input	Invalid Input	Invalid Input

Special Instructions

All programs require a $100 deposit to reserve a seat in the class. The deposit includes the WorkKeys assessment and re-test fees, where applicable. If the student does not meet program requirements or the class is not offered, $70 of the deposit will be refunded. PLCC does not accept online payments. Applicants may pay by mail, phone or in person. Cash, checks, money orders, and major credit cards are accepted.

Make checks payable to PLCC and mail to: Portage Lakes Career Center ATTN: Adult Education 4401 Shriver Road Uniontown, OH 44685
Applicant: Read Carefully!

I understand that this application places no obligation upon me or the school with regard to my admission until such time as I am accepted. My application will be reviewed and, if I am accepted, I will be notified by the Office of Adult Education

Yes, I certify that all statements made in this application are true.
Check box for e-signature

The Portage Lakes Joint Vocational School District is an equal opportunity educational institution. Employment and educational programs are offered without regard to race, color, religion, national origin, gender, disability, military status, ancestry or age. The district prohibits harassment of individuals in any form. Concerns of possible discrimination or harassment should be referred to Mr. Michael Kaschak, Compliance Coordinator, at 330-896-8200.