APPLICATION INFORMATION First Name: * Last Name: * Home Phone: * Cell Phone: Address Line 1: * Address Line 2: City: * State: * - - Choose One - - Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zipcode: * Email Address: *   EDUCATION INFORMATION Did you graduate from High School or complete your GED? * - - Choose One - - Not a High School Graduate Still Going to High School Completed GED High School Graduate Completed Some College College Graduate If so, what was/is the completion date? *   EMPLOYMENT INFORMATION Do you plan to work while attending ACH? Yes No If so, how many hours do you plan to work per week?   EDUCATION INVESTMENT Do you have funds set aside for your education? Yes No Will you be looking into financial aid? Yes No   MISCELLANEOUS Is English your primary language? Yes No What program are you interested in? * - - Choose One - - Massage/Physical Therapy Aide Medical Administrative Assistant Medical Assistant Medical Billing and Coding Pharmacy Technician Surgical Technology How did you hear about us? * - - Choose One - - Google Yahoo Bing/MSN Pennysaver E-Mail Referred by Friend Other