First Choice Training Institute Application

First Choice Training Institute
19 Keewaydin Drive
Salem, NH 03079
Phone: 603-890-8999

Complete this application form and remit the application processing fee of $60 within 5 business days to: First Choice Training Institute ATTN: On-Line Application P.O. Box 1307 Salem, NH 03079 Note: Your application will not be processed unless the processing fee is received within 5 business days.
Application for School Year Enrollment
Spring or Fall Semester	Year	Day or Evening Classes
Spring Fall		Day Evening

* Required Input

Personal Information

*First Name			Gender	Male
Middle Name			Gender	Female
*Last Name			Name you prefer to be called

Address			Telephone
City			Cell Phone
State			*email
Zip			Social Security Number	- -
Country			Date of Birth	/ / mm/dd/yy

Country of Birth		Non-Citizen Immigration Status
Citizenship		Veteran of US Forces	Yes No
First Language

Prior Education

High Schools Attended:

Name			Attendance From	/ mm/yy
Address			Attendance To	/ mm/yy
City, State Zip/Code			Graduation or GED Date	/ mm/yy

Name			Attendance From	/ mm/yy
Address			Attendance To	/ mm/yy
City, State Zip/Code

Post High School College/Institutes Attended:

Name			Attendance From	/ mm/yy
Graduation Date	/ mm/yy		Attendance To	/ mm/yy

Name			Attendance From	/ mm/yy
Graduation Date	/ mm/yy		Attendance To	/ mm/yy

Please Indicate Your Anticipated Program of Study:
	Medical Assistant		Phlebotomy		LPN Program
	Nursing Assistant with ESL		Dental Office Mgmt		Coding/Billing Mgmt
	Nursing Assistant

Other Information:

Do you intend to apply for financial aid?	Yes No
Have you visited First Choice for a tour?	Yes No
Have you visited for an interview?	Yes No

Optional race/ethnicity information complied for statistical purpose only.
Please select one:

	Black/non Hispanic		Asian/Pacific Islander
	American Indian/Alaska Native		White/Non Hispanic
	Hispanic		Other

Required Verification Section

* I, * do hereby Certify that the statements and information on this application are true to the best of my knowledge and belief.

I agree to comply with all the rules and regulations of First Choice Institute as printed in the catalog or otherwise prescribed, and to meet all financial obligations incurred by my attendance at First Choice Institute.

To verify for financial assistance, I agree to provide a copy of tax returns or any other official documentation necessary.

I give permission for First Choice to use, in booklets or other promotions, any college photograph in which this applicant may appear and/or his/her name.

I UNDERSTAND THAT CLICKING "APPLY" IS THE LEGAL EQUIVALENT OF MY MANUALLY SIGNING THIS APPLICATION.

In accordance with the Electronic Signatures in Global and National Commerce Act (E-Sign), your typed written signature constitutes a legal and binding application agreement that implies the information contained within is accurate to the best of your knowledge and belief.

(You must check the box and fill in your name to continue.)

Additional Information and/or Comments

Please click the apply button once and wait for us to process your information.
You will receive an email confirming your application.