PRIORITY APPLICATION

Anticipated Enrollment Date:______Social Security #:______Date of Birth: ______/______/______
Last Name:______First Name:______MI:______Place of Birth (City/State):______
Physical Address:______City:______State:______Zip Code:______
Mailing Address: ______City:______State:______Zip Code:______
(if Different from Physical Address)
Home Phone: (______)______Cell Phone: (______)______E-Mail:______
High School Graduate? ¨ Yes ¨ No Date or anticipated date of high school graduation (month/year):______/______
Name, city, state of high school:______
I started and finished my freshman year at a public high school in Florida? o Yes o No
Are you a High School student taking a course at FCTC for credit? o Yes o No Dual-Enrolled? o Yes o No School/Course:______
Are you employed: _____Yes _____No If yes, please complete the following: Occupation:______
Employer Name:______Phone #: (______)______
Mailing Address:______City:______State:______Zip Code:______
Emergency Contact Name:______Emergency Contact Phone #: (______)______
I would like information about: / Future Goal upon program completion at FCTC: / How did you hear about our school?
o Financial Aid
o FCTC Scholarships
o Payment Options
o N/A Self Paying Student
o Other:______/ o 2 Year Degree
o 4 Year Degree
o Graduate School
o Career Advancement
o Employment
o Other ______/ o Television
o Radio
o Newspaper
o Friend/Relative
o FCTC Website
o FCTC Event / o Place of Work
o Flyer/Mailer
o Social Media
o Former/Current Student
o FCTC Employee
o Other:______

I am applying for: ¨Fall ¨ Spring ¨ Summer ¨ Day ¨ Night/Saturday

¨ ADMINISTRATIVE OFFICE SPECIALIST
¨ AIR CONDITIONING, REFRIGERATION & HEATING / ¨ DENTAL ASSISTANT / ¨ MEDICAL ADMINISTRATIVE SPECIALIST
¨ AIRCRAFT FABRICATION / ¨ DIESEL TECHNOLOGY / ¨ MEDICAL ASSISTANT
¨ AUTOMOTIVE TECHNOLOGY / ¨ DIGITAL DESIGN 1 & 2 / ¨ NURSERY MANAGEMENT
¨ AUTOMOTIVE TECHNOLOGY - ADVANCED / ¨ EMERGENCY MEDICAL TECHNICIAN / ¨ NURSING ASSISTANT
¨ BARBERING / ¨ EMT/FIRE FIGHTING - COMBINED / ¨ PARAMEDIC
¨ COMMERCIAL FOODS & CULINARY ARTS / ¨ FIRE FIGHTING / ¨ PATIENT CARE TECHNICIAN
¨ COMPRESSED NATURAL GAS (CNG) / ¨ LANDSCAPE & TURF MANAGEMENT / ¨ PEST CONTROL OPERATIONS
¨ COSMETOLOGY / ¨ LEGAL ADMINISTRATIVE SPECIALIST / ¨ PHARMACY TECHNICIAN
¨ COSMETOLOGY - FACIALS SPECIALIST ONLY / ¨ LICENSED PRACTICAL NURSING / ¨ WELDING TECHNOLOGY
¨ COSMETOLOGY - NAILS SPECIALIST ONLY / ¨ MASSAGE THERAPY

Student Signature:______Date:______

Priority Application – Revised December 2015