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Certificate Seeking Application - Brigham City Campus

Section 1: Candidate Information
Page 1 of 1
Enrollment Information
1. 

What category best describes you?

*Required
2. 
Choose an academic year.
*Required
3. 

Program of Interest

*Required
Personal Information
4. 

Legal First Name

*Required, Maximum characters allowed: 30
5. 
Middle Name
Maximum characters allowed: 30
6. 

Legal Last Name

*Required, Maximum characters allowed: 60
7. 
Suffix
8. 
Email Address
*Required, Format: x@x.xx
9. 
What is your birth/maiden name?
Maximum characters allowed: 30
10. 
Date of Birth (mm/dd/yyyy)
*Required, Format: mm/dd/yyyy
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11. 
Gender (M/F)
12. 
Social Security Number
*Required, Format: 123-45-6789
Why is my Social Security Number required?
An eligible educational institution, such as a college or university, must get your correct identifying number to file certain information to the IRS and furnish a statement to you. For students, this will be your social security number (SSN). The returns they must file contain information about qualified tuition and related expenses (Form 1098-T), Tuition Statement. The information about your tuition will help to determine whether you or the person who can claim you as a dependent, may take either the tuition and fees deduction or claim an education credit to reduce federal income tax.  If you have questions about this, please contact Student Services for a W-9S.
13. 
Ethnicity
14. 
Race
15. 
What is your mobile/cell phone number?
*Required, Format: 123-456-7890
Permanent Address
16. 
Address 
*Required, Maximum characters allowed: 60
17. 
City
*Required, Maximum characters allowed: 25
18. 
State
*Required
19. 
Zip Code
*Required, Format: 12345 OR 12345-6789 OR 123456789 OR A1B 2C3
20. 
Home Phone Number (xxx-xxx-xxxx)
*Required, Format: 123-456-7890
Current Address (If Different from Permanent Address)
21. 
Address  
Maximum characters allowed: 60
22. 
City
Maximum characters allowed: 25
23. 
State
24. 
Zip Code
Format: 12345 OR 12345-6789 OR 123456789 OR A1B 2C3
25. 
Daytime Phone Number (xxx-xxx-xxxx)
Format: 123-456-7890
High School/GED Information
Students are required to have either a high school diploma or GED. Please choose GED or your high school and graduation date.
26. 

Please select the high school you attended.

*Required
27. 

High School Graduation Date (mm/dd/yyyy)

*Required, Format: mm/dd/yyyy
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Bridgerland Technical College Information
28. 

Have you previously attended Bridgerland Technical College?

*Required
Other College Information
29. 
Last College/University Attended
Maximum characters allowed: 120
30. 
Last Attended College/University City
Maximum characters allowed: 25
31. 
Last Attended College/University State
32. 
Beginning Attendance Date of Most Recently Attended College/University (mm/dd/yyyy)
Format: mm/dd/yyyy
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33. 
Ending Attendance Date of Last College/University Attended (mm/dd/yyyy)
Format: mm/dd/yyyy
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Other
34. 

Are you currently working?

*Required
35. 

Do either of your parents have a college degree (bachelor's degree or higher)?

*Required
36. 

How did you hear about us?

Military Service

Military Service

37. 

Active Military Service (Please choose)

38. 

Receiving Veterans Benefits?

39. 

Are you spouse or dependent of veteran/active duty?

40. 

Are you a spouse or dependent of a veteran who is deceased?

Optional
The following questions/answers will be used for Federal Reporting only. Please select yes for all that apply to you.
41. 

Are you a displaced homemaker? (This is an individual who has been providing unpaid services to family members in the home, been dependent on the income of another family member but is no longer supported by that income, and/or is underemployed and is experiencing difficulty in obtaining or upgrading employment.)  

42. 

Have you worked primarily without remuneration to care for a home and family and for that reason have diminished marketable skills, and are you unemployed or underemployed and experiencing difficulty in obtaining or upgrading employment? 

43. 

Are you currently in or have you previously aged out of the foster care system?

44. 
Is the predominate language spoken in your home something other than English?
45. 
Are you a single parent or single pregnant woman?
46. 

Do you lack a fixed, regular, and adequate nighttime residence?

Student Records Disclosure
In compliance with federal FERPA regulations, the college may release the following as directory information without student consent: name, program of study, date of attendance, certificate/degree awarded, honors received, and photo for publicity.  Students requesting that such information be withheld must complete the appropriate form requesting specifically which directory information should be suppressed. This form can be obtained from Student Services. Other specific information not listed above may be released provided the signed consent form is in the student's file. In accordance with FERPA 34 C.F.R., Part 99, Subpart D, certain governmental institutions have access to student records without prior consent for disclosure.
Notice of Nondiscrimination

Bridgerland Technical College (BTECH) does not discriminate on the basis of race, color, national origin, sex, age, or handicap in admission or access to, or treatment or employment in, its education programs or activities.  BTECH does not discriminate against anyone with a known bloodborne and/or infectious disease. Inquiries concerning Title VI, Title IX, and Section 504 may be referred to Renee Milne, BTECH, 1301 North 600 West, Logan, Utah 84321, or the Office of Civil Rights, U.S. Department of Education, 1961 Stout Street, Denver, CO 80294.

Certification of Information
By clicking the submit button I certify the information I have provided on this form is true and correct to the best of my knowledge. I also acknowledge that photographs, video and/or audio clips may be taken of persons in public areas such as classrooms, the Student Services Office, or on the school grounds. This documentation may be used for public relations without the expressed consent of the individuals represented. I understand that if I do not agree to these terms, I must complete a Denial of Consent form available in Student Services. 

In addition, I certify that I have read the student records disclosure.
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