APPLICATION FOR ADMISSION TO THE EDUCATOR PREPARATION INSTITUTE DATE (of this application) ___/___/_______ LAST NAME
FIRST NAME
MAIDEN NAME
MIDDLE NAME
*Valencia ID number (required) V_______________________ Telephone Number (
)
-
Alternate Phone Number (______)_________-_________
Address (Street)
Apt #
County
City, State, Zip Code
Atlas Email: Male
Female
Birth date: ___/___/_______
Ethnicity: (Please check one box) African-American/Black
Caucasian
Asian/Pacific Islander
Hispanic
American/Native Indian
Other
Background Information: Have you obtained a valid Statement of Eligibility from the Florida Department of Education?
Yes
No
Subject Area: _______________________________________________ Date Issued: ___/___/_______ Expiration Date: ___/___/_______ Note: You must attach a valid copy of your Statement of Eligibility with this application Have official transcripts been sent to the registrar?
Yes
No
Presently enrolled at Valencia College?
Yes
No
Date admitted to Valencia
____/____/_______
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