Career Training Center

6425 Bonny Oaks Drive Chattanooga, TN. 37416 (423) 892-3545 Fax: (615) 229-0399 APPLICANT INFORMATION Name: Date of birth: Current address: City: Cell : State: ZIP Code: SSN: Phone:

High School: Previous Colleges Attended:

Graduation Date: Degree(s) Earned?

Circle Program Applying For: 1. Three Month Program 2. Radiology 3. Coronal Polishing 4. Nitrous Oxide 5. Dental Sealants

EMERGENCY CONTACT Name of a relative not residing with you: Address: City: Relationship: CURRENT EMPLOYMENT INFORMATION Current employer: Employer address: Phone: City: Position: E-mail: State: Manager: REFERENCES Name Address Phone How long? Fax: ZIP Code: Owner: State: Phone: ZIP Code:

MEDICAL INFORMATION Date of Last Physical: Childhood Vaccinations Complete? Hepatitis Vaccination Current? History of Tuberculosis? SIGNATURES I authorize the verification of the information provided on this form. I have received a copy of this application. All information received in this application is confidential , only authorized school officials have access to its content Signature of applicant: Current Registration/License # (If Applicable) Date: ***Attach Copy Of Registration License