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COURSE APPLICATION FORM

Pipe Welding / W414

Course Selection

I am interested in:*

Start Date:*

Alternate Date:

Personal Data

If no middle name, please write "none"

Social Security Number*

Gender* Male Female Prefer Not to Disclose

Race*
Alaskan Native American Indian African American Asian Pacific Islander Caucasian Hawaiian Hispanic Prefer Not to Disclose Other

Emergency Contact Information:

Relationship:

Housing Information

I will be living at/with*
Home Family/Friends Hotel

If hotel is selected, please write name of hotel

Employment Status/Experience

I am
Employed Unemployed

Are you or were you
Full time Part time Seasonal On-Call None of these

I am
Collecting unemployment benefits
Eligible to collect unemployment benefits
Not collecting unemployment benefits

I am
Veteran Out Processing Active Duty None of these

Employment Goals

Employers I am interested in:

Positions I am interested in:

Please describe what job or jobs you would like to be employed in after completing this training:

Funding Information

Please indicate how you intend to pay for your training (tuition, fees, books, tools, supplies, room and board). It is highly recommended that you apply for grants and scholarships to help fund your training. Please mark which agencies you intend to apply with

Personal Funds

Yes No

Alaska Student Loans

Yes No

Scholarships

Yes No

Alaska Native Scholarships

Yes No

State of Alaska Grants

Yes No

(State of Alaska Dept of Labor-Workforce Development, Dept of Vocational Rehabilitation, Bureau of Indian Affairs)

Employer Funded

Yes No

Please complete the area below IF you already know which agencies will be assisting you financially:

Educational Background

High School:

OR GED:

Post-Secondary Attendance
Have you ever attended any prior post-secondary academic or vocational institution?

Yes No

If yes, please list:

Health Questionnaire

Please indicate if you have any of the following medical conditions:

Vision impairments Eye loss Color blindness High blood pressure Difficulty in hearing Epilepsy Limb loss Diabetes Heart problems Back or knee injuries

I understand that I may be required to lift up to 50 pounds. Training may require constant bending, twisting, stooping, lifting, climbing of stairs or hills, and sitting or standing for extended periods of time, in all types of weather

Personal Plans

Please describe your personal plans upon training completion.

Statement of Correctness, Understanding, Authorization and Privacy Act Waiver

I understand that I must submit a $25 non-refundable application fee for all programs Longer than 80 Hours with this application.

I have read and understood all NIT Admission and Training Policies. (viewable here)

I understand that my program may require a drug screen and physical exam. I understand that these are mandatory to participate in that program.

I understand and consent that if enrolled; I will be placed in a random drug testing database and could be called at any time for a retest. I understand that if I fail a drug test, at any time, I will be released from training.

I understand that there are physical demands of working in Alaska. I have suitable outdoor work gear such as work boots, warm jacket, pants, coat, hat, etc.

I understand Northern Industrial Training, LLC courses that are less than 80 hours and testing fees are non-refundable. For courses 80 hours or longer, the student enrollment contract (refund policy) applies.

I hereby attest that all the information I have provided to Northern Industrial Training, LLC is true, correct, and complete.