rban Ed welcomes your Application for Enrollment!

A decision will be made within two weeks of receipt of your application. If you have questions, call 202-610-2344.

Which program are you applying to? A+ PC Technician/Network Certification [Advanced students only] Microsoft Office 2003 Certification [Moderate computer knowledge required] Basic IT Jobs Program (IC3 Certification) [Beginners welcome to apply]
Your Name:
Address:
City/State/ZIP:
Area Code & Phone Number
Area Code & Fax Number
E-mail Address (if any):
Social Security Number
Date of Birth
Name of parent or legal guardian if under 18
Gender Female Male

What race do you belong to or identify with? African-American/Black American Indian/Alaska Native Chinese/Chinese-American East Indian/Pakistani Filipino/Filipino-American Japanese/Japanese-American Korean/Korean-American Mexican/Mexican-American/Chicano Hispanic/Hispanic-American Pacific Islander Vietnamese/Vietnamese-American White/Caucasian Other, please specify
Do you currently work? Yes No
If yes, tells us where, your duties, work schedule and your weekly pay:
Are you a U.S. citizen? Yes No
Country of citizenship
If nonimmigrant, type of visa you hold, have applied for or plan to apply for? Immigrant/U.S. Permanent Resident Refugee Nonimmigrant
Did you drop out of school? Yes No
If yes, why did you drop out?
Highest grade completed?
Have you received your: Diploma GED
What is your annual household income level? Less than $10,000 $10,000 - $25,000 Over $25,000
How many people are in your household? 1 2 3 4 and over
Are you currently or have been on welfare, TANF or public assistance? Yes No
Have you ever been convicted of a misdemeanor or felony within the past five years? Yes No
If yes, please explain?
Have you ever been convicted of a drug related charge? Yes No
If yes, please explain?
Do you have a driver's license? Yes No
In your own words what in life is most important to you right now?
How much do you know about computers? Not much at all A little A lot
What do you like about computers?
Do you have any disabilities that limit your activity (include such things as Carpal Tunnel Syndrome)? If so, list below.
Why are you interested in our technology learning program(s)?
What times are best for you to attend classes? Daytime at 9:30 am or 10:00 am Evening at 5:30 pm or 6:00 pm Does not matter
What other things beyond computers are you interested in? Select all that apply. Carpentry Childcare Community Development English Electronics History Legal/Law Music Media Medicine Owning your own business Political process Sports Teaching
Other, please list.
Once you complete this program what do you hope will happen? What would be your goals?
If nothing else mattered, what would be your dream job?

How did you hear about us? Select all that apply. Friend Parent Word on the street School program Court system Mailing/Flyer Support service agency Counselor/Case Manager Another nonprofit Passing by/Walk-in Other