Registration

Please complete the form below to send us an email. Fields marked with * are required in order to submit the registration form.

APPLICANT

Legal Name*
Telephone*
Email Address*
Permanent Home Address
Mailing Address

DEMOGRAPHICS

US. Citizen?

Yes No

Birthplace
Years lived in the US?
Years outside the US?
Years lived in the NC?
Language Proficiency

Hispanic or Latino?

Yes No

Briefly list any academic distinctions or honors you have received.

HONORS

EXTRACURRICULAR & WORK EXPERIENCE

Experience
Location
Date

EDUCATION

Secondary Schools

Most recent secondary school attended
Entry Date
Graduation Date
Address
City
State
Country
Zip

Colleges and Universities List all colleges/universities you have attended:

College/University Name
Location(City/State/Zip)
Dates Attended

College/University Name
Location(City/State/Zip)
Dates Attended

College Credits Earned:

Degree(s) Earned:

Please send all official transcripts of high school and college/universities as soon as possible to:
BEATTIES FORD ROAD VOCATIONAL REHABILITATION CENTER
1406 Beatties Ford Road
Charlotte, N.C. 28216

Current Training(s): Please list all training(s) you have taken:

Please briefly elaborate on one of your extracurricular or work experiences in the space below that relates to the certification you are endeavoring to receive.

Additional Information: Please attach a separate sheet if you wish to provide details of circumstances or qualifications not reflected in the application.

DISCIPLINARY HISTORY

1. Have you ever been found responsible for a disciplinary violation at any educational institution you have attended from the 9th grade forward, whether related to academic misconduct or behavioral misconduct that resulted in a disciplinary action? These actions could include, but are not limited to; probation, suspension, removal, dismissal, or expulsion from the institution
Yes No

2. Have you ever been adjudicated guilty or convicted of a misdemeanor, felony, or other crime?

Yes No
(note that you are not required to answer “yes” to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded, or otherwise ordered by a court to be kept confidential.)

If you answered “yes” to either or both questions, please attach a separate sheet of paper that gives the approximate date of each incident, explain the circumstances, and reflect on what you learned from the experience.

Note: Applicants are expected to immediately notify the Beatties Ford Road Vocational Rehabilitation Center of any changes to the information requested in this application

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