New Student Registration Form | ABC Central Ohio Chapter

Applicant Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Gender*

Male
Female

Are you a citizen of the United States?*

Yes
No

If no, are you authorized to work in the U.S.?

Yes
No

Have you been convicted of a felony?*

Yes
No

If yes, explain.

Birth/Residency

Date of Birth*

Have you lived in Ohio for 12 months or more?*

Yes
No

Ethnicity

Choose one*

Education

Did you graduate from high school?*

Yes
No

Please attach a copy of your high school diploma or GED certificate

High school you graduated from?

City

State

Graduation date:

Did you participate in a Tech Prep/Vocational/Career Center Program?

Yes
No

Veteran Status

Are you a Veteran?*

Yes
No

If yes, please attach a copy of your DD-214

Are you Active Duty?*

Yes
No

Employer

Please name your employer

Emergency Contact Information

Contact:

Relationship:

Phone

PREFERRED LOCATION FOR INSTRUCTION:

please choose location:*

ABC Central Ohio (1725 Jetway Blvd., Columbus OH 43219) Trades offered: Carpentry, Electrical, HVAC, Plumbing
Pioneer Career & Technology Center @ Kehoe Center (175 Mansfield Ave., Mansfield OH 44902) Trades offered: only Electrical at this time

In-house Apprenticeship (please specify location):*

Trade Program (please choose one):*

If "Other", please type here:

Year/Level (please choose one):

I hereby authorize the ABC Central Ohio to verify information provided in my application, and to release this information to potential employers when appropriate. To the best of my knowledge, the information provided is complete and correct.

Signature (type your full name)*

Date