Kentucky Community & Technical College System
LAST NAME: _______________________________ FIRST NAME: __________________________________ MIDDLE NAME: _________________________
E-MAIL ADDRESS (if you PREFER MESSAGES VIA EMAIL) _________________________________________________________________________________
HOME PHONE NO. ___________________________________ WORK OR CELL PHONE NO. _____________________________________________________
MAILING ADDRESS _______________________________________________________________________________________________________________
CITY, STATE, ZIP, COUNTY __________________________________________________________________________________________________________
HIGH SCHOOL ATTENDED __________________________________________________________________________________________________________
(If you earned a GED enter GED for High School)
HIGH SCHOOL GRADUATION or GED COMPLETION DATE _________________________________________________________________________________
Date of Birth_________________________*Gender Male Female
Month Day Year
Citizenship Status US Citizen Yes No
If not a US citizen are you a permanent resident alien of the US? Yes No Resident Alien Number ________________________________________
*Do you consider yourself Hispanic/Latino? Yes No
*In
addition, select one or more of the following racial categories to describe yourself:
American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White
*Optional information requested for reporting purposes and will not be used in an admission decision.
Please list all the names that you have used on previous KCTCS records. ________________________________________________________
Admit Status First-Time College Student Readmit (attended KCTCS previously)
High School (taking college courses prior to High School graduation)
Residency Status Kentucky Have you lived in Kentucky for the last 12 months? Yes No
Non-Kentucky How long have you been living in your non-Kentucky county? _____________________________________
ARE YOU CURRENTLY EMPLOYED BY A UTILITY? Yes No IF YES, WHAT UTILITY _______________________________________________________
EMPLOYER NAME & ADDRESS ______________________________________________________________________________________________________
YEARS OF EXPERIENCE ________ LEVEL OF SERVICE (Apprentice, Journeyman, Serviceman, etc.) ________________________________________________
WHAT EQUIPMENT DO YOU OPERATE IN YOUR CURRENT POSITION: _____________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
DO YOU CURRENTLY HAVE A CDL (A) LICENSE? Yes No
IF NO, DO YOU HAVE A LEGAL UNITED STATES DRIVER’S LICENSE? Yes No
DO YOU UNDERSTAND THE PHYSICAL REQUIREMENTS FOR THE CLASS? Yes No
Lineman Training School
APPLICATION
