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Please
print and mail with your check to:
Attention:
Linda Mitchell
Beaver
County Area Vocational Technical School: 145
Poplar Drive Monaca,
PA 15061
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Application Date
Mr.
Mrs.
-
-
Miss
_____
Social
Security No. First Name
Initial
Last Name
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(
)
Street
Address
City
State
Zip
Birth-date Phone
No.
Check
One:
oAmerican
Indian oAsian
oBlack
oWhite oHispanic
School District
In Which You Live
Check
All That Apply: oDisabled
oDisplaced
Homemaker oEconomically
Disadvantaged
oNon
Traditional
oEducationally
Disadvantaged
oLimited
English Proficiency
oSingle
Parent
Check
Where Most Appropriate:
I
am taking this course……..
o
A. To prepare for a new occupation.
o
B. To upgrade my skills for my present occupational field.
o
C. Because it is part of my apprenticeship program.
o
D. As a means of self-development or other non-occupational reason.
/
/
Course
Title
Course Day
Course Time
Course Date
For
Emergency Purposes:
(
)
Place
Of Employment
Work Phone No.
I certify that the above is my official place
of residence. I understand the registration fee is non-refundable
unless the course is cancelled.
This
registration is confirmation of your employment in the above course.
If unable to attend, please notify the Adult Education Office at
(724) 728-5800.
DO
NOT WRITE BELOW THIS LINE
- For
Office Use Only
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Amount Due
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Date Paid
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Amount Paid
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Check No.
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Cash
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REGISTRATION
FEE:
(Non-Refundable)
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Registered
by:
Make
all fees payable to: Beaver
County BCCTC
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