Date (mm/dd/yyyy):

First Name:

Middle Name:

Last Name:

Home Address:

City:

State:

Zip:

Home Phone (xxx) xxx-xxxx:

Cell Phone (xxx) xxx-xxxx:

Email Address:

Employment Status:

Employed full-time

Employed part-time

Unemployed

Are you currently enrolled in an education or training program at the SVHEC or elsewhere?

Yes

No

If you answered "yes" above, please specifiy which program:

Education/training end date (mm/dd/yyyy):

Are you currently registered with the Virginia Employment Commission's One-Stop career center?

Yes

No

National Career Readiness Certificate Level:

Platinum

Gold

Silver

Bronze

Not applicable

Not familiar with this certification

IT certifications/experience:

Are you a current member or veteran of the US military?

Yes, current member

Yes, veteran

No, neither

Your availability for training (check all that apply):

Weekdays, 8:00 a.m. - 12:00 noon

Weekdays, 12:00 noon - 5:00 p.m.

Weekdays, 5:00 p.m. - 9:00 p.m.

Saturdays, 8:00 a.m. - 4:00 p.m.

Are you available to begin classes in (check all that apply):

August 2017

January 2018

How did you hear about training programs at the SVHEC (Referral Source)?:

  
We are committed to designing this program to meet the needs of our students.  Would you rather attend class 3 times per week for 4-5 months to complete the full curriculum, or would you rather attend class twice a week for 6-7 months?  

Meet 3 times per week 4-5 months

Meet twice per week for 6-7 months

  
What is the best time for our staff to contact you?

Information Received By:

Comments/Notes:

Follow-up Date (mm/dd/yyyy):