Application — eKentucky Advanced Manufacturing Institute
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Contact Us
TAKING APPLICATIONS NOW!
Phone:
606-789-8568
Fax: 606-789-4059
Course Name: CNC Machinist Now
APPLY ONLINE HERE
OR
DOWNLOAD
AND MAIL TO
:
P.O. Box 1718
Paintsville, KY 41240
Download Paper Application Here >>
ONLINE APPLICATION
Name
*
First Name
Last Name
Marital Status
*
Single
Married
Divorced
Widowed
Date of Birth
*
MM
DD
YYYY
Age
*
Sex
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
County
*
Social Security Number
*
*eKAMI will request Social Security Numbers (SSN) at the time of application. The SSN will not be used as the student ID number but will be provided to entitles requiring SSN. Your SSN may be used in connection with developing, validating or administering predictive tests and assessments; Improving Instruction; internal identification of students; collection of student debts. Students who choose to not provide their SSN will be ineligible for financial aid. If you provide your SSN to eKAMI, you will consent to allow eKAMI to use numbers in manner described.
Home Phone
*
(###)
###
####
Cell Phone
*
(###)
###
####
Email Address
*
eKAMI is committed to affirmative action goals and would appreciate your response to the following:
Have you ever been convicted of a felony?
*
Yes
No
If Yes, Answer Below
Please include a separate page with all charges, year and location.
Are you a U.S. Citizen?
*
Yes
No
Other
Are you a resident of Kentucky?
*
Yes
No
Are you a veteran of the U.S. Military?
*
Yes
No
If a Veteran, do you have a VA disability rating?
*
Yes
No
Have you been laid off from a job for which you drew Unemployment Insurance?
*
Yes
No
If yes, have you worked full-time since drawing Unemployment Insurance benefits?
*
Yes
No
If you are age 24 and under, do any of the following apply to you?
Do you have children?
Yes
No
Are you homeless?
Yes
No
Were you ever in the foster care system?
Yes
No
Are you a high school drop out?
Yes
No
Have you been fired within the previous 12 months?
Yes
No
Have you ever worked a full time job?
Yes
No
If employed, is your hourly wage less than $13.40/hour?
Yes
No
Not Employed
Work History
Please enter employment history from most recent to oldest.
Employer Name
Dates: From/To
Position Held
Reason for Leaving
Contact
Other Jobs (If Applicable)
Employer Name
Dates: From/To
Position Held
Reason For Leaving
Contact
Employer Name
Dates: From/To
Position Held
Reason for Leaving
Contact
Employer Name
Dates: From/To
Position Held
Reason For Leaving
Contact
Education
Name of School or Institution
Attended: From/To
City, State
Degree/Certifications
Name of School or Institution
Attended: From/To
City, State
Degree/Certifications
Name of School or Institution
Attended: From/To
City, State
Degree/Certifications
Name of School or Institution
Attended: From/To
City, State
Degree/Certifications
SPONSOR/COMPANY INFORMATION
If you are receiving assistance from an employer, Big Sandy Action, etc. Please fill out the following
Company Name
Location
Address (if different)
Contact/title
Company Name
Location
Address (if different)
Contact/title
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address)
Relationship
Home Phone
(###)
###
####
Work Phone
(###)
###
####
My enrollment with eKAMI will signify my consent to and acceptance of all policies and procedures governing my enrollment, including financial liability. If I fail to remit payment when due, I promise to pay eKAMI all reasonable cost for collection, including collection agency fees.
*
Agree
Name
*
Date
*
MM
DD
YYYY
Thank you!
