New Student Application | Instrument Repair School

Prospective Student Application

Please fill out the following form. By submitting this application you are confirming that the information provided is completely accurate to the best of your knowledge.

First Name *

Last Name *

Birthdate *

Gender

Male
Female

Email *

Phone Number *

Number Type

Mobile
Home
Work

Best Time to Call *

Give a few general day and time options

City *

State *

Zip Code *

Address

Shipping (If Different) – Include city, state, and zip

Emergency Contact *

Emergency Contact Phone Number *

Relationship to Emergency Contact *

Date of Most Recent Tetanus Shot *

Month and Year

Education History *

High School, Post-Secondary, Trade, etc

Recent Work History

Job Titles, Company Names, Timeline, etc.

Interests/Talents/Hobbies *

Why are you interested in training at CIOMIT? *

CIOMIT Course Interest *

Which courses do you want to take at CIOMIT?

Program Format Preference *

On Campus: Power Course
On Campus: Full Program (12 Month)
On Campus: Full Program (9 Month)
Online

Desired Start Date *

Comments

more details

CIOMIT Repair Institute Student Application