HEALTH CAREER TRAINING ASSOCIATES, LLC
60 Rogers Street
Manchester, NH 03103
603 622-8400
                                  
STUDENT APPLICATION

PLEASE PRINT IN INK.
*Your answer to these questions is optional.  They are useful to us for statistical purposes & educational planning.

Last Name ____________________________First Name________________________________MI_____

Address________________________________________  E mail__________________________________

City ___________________________________________State __________Zip_____________________

(H) Phone Number ___________________________(C) Phone Number___________________________

*Date of birth_____/______/______                        Social Security Number  ____________________________

Will you be receiving funding through an agency ?_____Yes _____No
If Yes, Which agency? ________________________________________________________________
Contact Person _____________________________________________________________________
Are you a U.S. citizen? _____Yes _____No  
Language other than English (spoken or written):_______________________________________

Please circle the highest level of education you have completed:  
           6      7      8      9      10      11      12   GED  Year:__________
College-Post grad   Other post-secondary education? _____________________________

When do you anticipate entering a program? ____________Year_________

Which program are you applying to?_____________________________________________

Emergency Contact Person:
Last Name _____________________________First name___________________________
Relationship_______________Address__________________________________________
City____________________________State___________________ZipCode___________
(H) Phone number_________________________(W) Phone__________________________
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The information provided on this application is considered to be confidential.  Health Career Training Associates reserves the right to
deny admission to any applicant who does not possess the adequate skills needed for a reasonable chance of success in his/her
chosen program.
I certify that I have read and understand the above statement. I certify that the above information that I have provided is complete and
true. If accepted, I agree to abide by the student policies as noted in the Student Handbook.

Applicant Signature_______________________________________________Date__________________

Mail Application with non-refundable $150.00 fee to:        Health Career Training Associates   
                                                                                                       60 Rogers Street   Manchester, NH 03103     
Make check payable to HCTA                                    

                                Do Not Write below this line
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OFFICE USE ONLY:   ROUTING
Posted  Date________ Receipt sent  $_______Paid   Check #_______  Credit Card______  Agency Auth. _________
Posted SIS __________HOBET _________  Interview ___________   
Sent to NESPN Admissions for NET date__________
Posted to Pre-entrance Roster _________Test results received _________  Acceptance_______Y______N      
Orientation / Confirmation/invoice/ Course info and book list sent.
Date ___________________ Amount  Deposited________________________