I acknowledge that having a previous criminal record containing a felony may prohibit my participation in a secondary program and may create a barrier to program completion. I agree to a private meeting to disclose any previous felony convictions prior to the start of the program for which I am applying. I understand that failure to disclose information prior to the start of the program or while enrolled may result in immediate termination from the program.

First NameRequired

Last NameRequired

SuffixRequired -- choose one -- CPA DDS Director Esquire I II III IV Jr. MD P.E. PHD RN Sr. U S Air Force U S Coast Guard U S Marine Corps U S Navy United States Army V VI VII

Email AddressRequired

Social Security NumberRequired

Date of BirthRequired

GenderRequired -- choose one -- Female Male Unknown

HispanicRequired -- choose one -- NO YES

EthnicityRequired -- choose one -- AMER. IND/ALASK ASIAN/PAC ISLAND BLACK, NON HISP CAPE VERDEAN EGYPTIAN HAITIAN HISPANIC OTHER WHITE, NON HISP

Citizenship StatusRequired -- choose one -- Non-Resident Alien Resident Alien US Citizen

Citizenship CountryRequired -- choose one -- UNITED STATES CANADA AFGHANISTAN ALBANIA ALGERIA ANDORRA ANGOLA ANTIGUA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA BOTSWANA BRAZIL BRUNEI BULGARIA BURKINA FASO BURMA BURUNDI CAMBODIA CAMEROON CAPE VERDE CENTRAL AFRICAN REPUBLIC CEYLON CHAD CHILE CHINA COLOMBIA COMOROS CONGO COSTA RICA CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ENGLAND EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FIJI FINLAND FRANCE FRENCH ANTILLES FRENCH GUIANA GABON GAMBIA GEORGIA GERMANY GHANA GREECE GRENADA GUADELOUPE GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HOLY SEE HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY IVORY COAST JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA KUWAIT KYRGZSTAN LAOS LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW ZEALAND NICARAGUA NIGER NIGERIA NORTH KOREA NORTHERN IRELAND NORWAY OMAN PAKISTAN PALAU PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL PRINCIPE QATAR REPUBLIC OF CHINA ROMANIA RUSSIA RWANDA SAN MARINO SAO TOME SAUDI ARABIA SCOTLAND SENEGAL SERBIA SEYCHELLES SIERRA LEON SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH KOREA SOUTH-WEST AFRICA SPAIN SRI LANKA ST. KITTS ST. LUCIA ST. NEVIS ST. VINCENT SUDAN SURINAME SWAZILAND SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKSTAN TANZANIA THAILAND THE GRENADINES TOBAGO TOGO TONGA TRINIDAD TUNISIA TURKEY TURKMENISTAN TUVALU UAE UGANDA UKRAINE UNITED KINGDOM UPPER VOLTA URUGUAY UZBEKISTAN VANUATU VATICAN CITY VENEZUELA VIETNAM WALES WEST AFRICA WEST INDIES WESTERN SAMOA YEMEN ZAIRE ZAMBIA ZIMBABWE

Street 1Required

Street 2Required

CityRequired

StateRequired -- choose one -- ALABAMA ALASKA AMERICAN EMBASSY AMERICAN SAMOA ARIZONA ARKANSAS ARMED FORCES THE PACIFIC CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM 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 PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Zip CodeRequired Zip Code Extension

US Cell PhoneRequired US Cell Phone Area Code US Cell Phone Exchange US Cell Phone Number US Cell Phone Extension  Ext: 

School Level CompletedRequired -- choose one -- College GED High School

Prior School Grad YearRequired -- choose one -- 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929

Program of InterestRequired -- choose one -- General Enrollement LPN Part-Time Medical Assisting CDL Class A (240 Hours) CDL Class B Auto Tech Welding (400 Hours) Welding (100 Hours) Electro Mechanical Technology

Anticipated Starting SemesterRequired -- choose one -- General Enrollment 23/24 CDL A Day (06/10/2024) Auto Tech - Term 2 Auto Tech - Term 3 Auto Tech - Term 4 General Enrollment 24/25 PN 0724PT Term 1 (07/2024) CDL A Evening (07/29/2024) CDL A Day (09/30/2024) CDL A Day (11/04/2024) CDL A Day (12/30/2024) CDL A Day (02/10/2025) CDL A Evening (03/24/2025) CDL A Day (06/02/2025) Medical Assisting (07/2024) WD FT (09/24/2024) WD PT (09/24/2024) WD PT (11/12/2024) WD PT (01/08/2025) WD PT (02/25/2025) General Enrollment 25/26 General Enrollment 26/27 General Enrollment 27/28 General Enrollment 28/29

VeteranRequired -- choose one -- No Yes

Have you been a resident of Pennsylvania for two or more years?Required -- select one --NO Yes

Place of birth (if outside the USA, please enter the date you first entered the US).Required

If you have graduated from STC within the last 3 years please indicate the program and graduation year. If not, please write NA.Required

If you are currently seeking or are approved for funding, please indicate the Company/Agency and Contact information below.Required

If you will be using GI Bill Benefits, please list the Benefit Chapter if known.Required

Signature and DateRequired

TEAS Test Date RequestingRequired -- select one --Not applying for the LPN program Passed TEAS elsewhere February 20, 2024 - 8:30AM February 20, 2024 - 4:30PM March 19, 2024 - 8:30AM April 23, 2024 - 8:30AM May 21, 2024 - 8:30AM

Driver's License #:Required

The application will not be processed without payment of the nonrefundable application fee. (If you are an STC grad within the last 3 years please contact the school 570-874-1412)

To be scheduled for the TEAS test a separate fee of $80 is required. Please contact the school to pay and confirm test date.