Address: US
Price range: $$

Welcome to our new online application. Please complete each section of the form. Once you submit the form you will be directed to make the online payment, After payment, please wait to see our 'Thank You for Your Registration' page before closing.
You can also download and print the form if choose using the link below.

If you choose, you can also download and print the application. Click to Download PDF Version
You will need to contact the office for payment.

Online Admission Application Form

Instructions: Answer all questions. There will be a $50.00 Nonrefundable Registration and Testing Fee for Dental Assisting, Practical Nursing and Surgical Technology while $30.00 for Central Service Technician (CRCST) by submitting this form.

Personal Information

First Name:

Middle Initial:

Last Name:

Previous Last Name (if applicable):

Street Address:

County:

City:

State:

Zip:

Primary Phone:

Secondary Phone:

Email:

Social Security Number:

Date of Birth: MM/DD/YYYY

Age:

Gender

Female

Male

Program of Interest

Central Service Technician (CRCST)

Dental Assisting

Practical Nursing

Surgical Technology

All programs require the TABE entrance exam that has a non-refundable fee of $20.00 paid at the time of testing.

Educational History

Highest Level of Education (check only one):

High School

High School Equivalent

Associate's Degree

Bachelor's Degree

Post-Baccalaureate

Degree Major(if applicable):

Name of High School/Testing Location:

City/State of High School/Testing Location:

Grad/HS Equivalent (MM/YYYY):

Colleges or Post-Secondary Programs you have previously attended:

Name of School/College:

From (MM/YYYY):

To (MM/YYYY):

Name of School/College:

From (MM/YYYY):

To (MM/YYYY):

Do you have a current STNA Credential?

Yes , Renewal Date:

Funding Information:

Pell Grant

Interest-Free Payment Plan

Student Loan

MCTA/TCTA/WIOA Funds

Other (specify)

Are you in default on any student loans?

Yes

Are you a Veteran?

Yes , Which branch:

Employment Data:

Currently Employed?

Yes

Current or Last Employer:

From (MM/YYYY):

To (MM/YYYY):

Current or Last Position:

Employment type:

Full-time

Part-time

Emergency Contact:

Name:

Relationship:

Phone:

Address:

City:

State:

Zip:

Authorization for Release of Information and Applicant Certification:

I hereby authorize the release of information to Choffin Career and Technical Center including information both oral and/or written regarding my records, character, conduct and performance. I understand that all pre-entrance requirements must be met and a criminal background check and satisfactory drug screen are required for participation in each program and clinical externship. I further certify the information given on this application is true.

Applicant Name

Status: Empty Signature!

Applicant Signature

After signing, remember to click the Save Signature button.

Date

For Payment Details:

Email:

Use the same email above

Payment Mode:

Total amount due(USD):

Admission

Programs

Continuing Ed

Testing

Student Services

Admission Application

Online Admission Application Form

Personal Information

Program of Interest

Educational History

Funding Information:

Employment Data:

Emergency Contact:

Additional Information:

Reporting Information:

For Payment Details:

Contact

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