Registration

Please complete the form below to send us an email. Fields marked with * are required in order to submit the registration form.

APPLICANT


DEMOGRAPHICS

US. Citizen? 
  
Hispanic or Latino? 
  
Briefly list any academic distinctions or honors you have received.

HONORS


EXTRACURRICULAR & WORK EXPERIENCE







EDUCATION

Secondary Schools


Colleges and Universities List all college/universities you have attended:





Please send all official transcripts of high school and college/universities as soon as possible to:
BEATTIES FORD ROAD VOCATIONAL REHABILITATION CENTER
1406 Beatties Ford Road
Charlotte, N.C. 28216



Additional Information: Please attache a separate sheet if you wish to provide details of circumstances or qualifications not reflected in the application.

DISCIPLINARY HISTORY

1. Have your ever been found responsible for a disciplinary violation at any educational institution you have attended from the 9th grade forward, whether related to academic misconduct or behavioral misconduct that resulted in a disciplinary action? These actions could include, but are not limited to; probation, suspension, removal, dismissal, or expulsion from the institution
  

2. Have you ever been adjudicated guilty or convicted of a misdemeanor, felony, or other crime?
  
(note that you are not required to answer “yes” to this question, or provide an explanation, if the criminal adjudication or conviction has been expunged, sealed, annulled, pardoned, destroyed, erased, impounded, or otherwise ordered by a court to be kept confidential.)

If you answered “yes” to either or both questions, please attach a separate sheet of paper that gives the approximate date of each incident, explain the circumstances, and reflect on what you learned from the experience.

Note: Applicants are expected to immediately notify the Beatties Ford Road Vocational Rehabilitation Center of any changes to the information requested in this application



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