Allegheny Valley Institute of TechnologyÒ

APPLICATION FORM

Name: Last ______First ______MI ______

Home Phone: ( ) ______Social Security Number ______

Work Phone (if applicable): ( ) ______

Date of Birth: ______Sex: Male Female

U. S. Citizen Yes No If no, country of citizenship: ______

Ethnic Origin: ______ (Voluntary)

Local address (including zip code) ______

Permanent address (including zip code) ______
______

Internet (e-mail) address: ______

Emergency Contact:
Name
Address
Phone

Program of Study applying for:: ______

Educational Background of Student
Name of School
Attended/Attending
(in chronological order) / Type of School
(Primary)
Secondary, etc) / Date Joined
(DD/MM/YYYY) / Date Left
(DD/MM/YYYY) / Highest Level Passed

Academic Achievements:

High School Diploma? Yes No If no, please provide GED Score:______

References of at least three individuals who can validate your interest in computer technology:

Name Phone


1.______

2.______

3.______


I certify that all information contained in this application is correct and complete to the best of my knowledge. I understand that withholding and/or giving false information on this application may make me ineligible for admission or later subject to dismissal. If admitted to the Allegheny Valley Institute of TechnologyÒ, I agree to abide in accordance with the regulations of the institution as explained in the School Catalog and Student Guide.

Applicant Signature * Application Fee Enclosed

Date:

Parent’s Signatureand accompanying information is required if the applicant is less than 18 years of age:

Parent Signature: Date:

Address:

Phone Number:

*An Application Fee of $35 must be submitted with this application. If you mail this application, enclose a check or money order made payable to the Allegheny Valley Institute of Technology and send it to the Admissions Office. The entire fee will be refunded if the applicant is found to be ineligible or not acceptable for admission. This fee is not refundable after five calendar days have elapsed. The MicroPower Institute of Technology reserves the right to accept or reject any applicant.

Please return Application Form to:

Allegheny Valley Institute of Technology®

One Kiski Avenue, Leechburg, PA 15656

Attention: Admissions

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