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CONTINUING EDUCATION APPLICATION
When do you plan to begin classes? Fall r Spring r Summer r Year___ ___ ___ ___
(May-August)
(Aug-Dec) (Jan-May)
Fee
Paid _____________
Billed____________
Date _________________
Revised 11/13/14
01 College
08 Students
08 Classes
1. Social Security Number: __ __ __ -__ __ -__ __ __ __ 2. Name:_____________________________________________________________________________________________________________________
Last First Middle
Please list any other name you have used for work or school, including maiden name: ____________________________________________________
3.Address:___________________________________________________________________________________________________________________________________________
Street
City
4.Email:___________________________________________
5. County: ________________________________________
6.Day phone: ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Evening phone: ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
Cell phone: ___ ___ ___ - ___ ___ ___ - ___ ___ ___ ___
7.Gender: r Male r Female 8. Birth date: ___ ___ - ___ ___ - ___ ___ ___ ___
mm dd yyyy
9. U.S. citizen: r Yes r No
If no, what is your VISA type?_____________________________
10. Are you Hispanic or Latino? r Yes r No
If not, check all that apply:
r American Indian or Alaskan Native
r Asian
r Black/African American
r Native Hawaiian/other Pacific Island
r White
r Unknown
11. Have you lived at your current address for at least one year? r Yes r No
If less than one year, please list all addresses used in the last 12 months and length of time at each.
___________________________________________________________________________________
From _______________________________________To:___________________________________
__________________________________________________________________________________
From _______________________________________To:___________________________________
CRN
State
Zip
12. Are you a West Virginia resident? r Yes r No
13. High School Completion Status:
r High school graduate
r GED™/TASC certificate holder
r Home schooled
r Did not graduate high school/no GED™/TASC
14. Year of High School (GED™/TASC) Graduation ___ ___ ___ ___
High school ______________________________________________
City/State ______________________________________________
15. Did you attend WVNCC prior to 1990? r Yes r No
16. Which best describes why you are taking this course?
r Personal interest
r Workplace skills
17. Which campus will you be attending?
r Wheeling r New Martinsville
r Weirton
r Distance (Online Courses)
I certify that all the information provided in this application is complete and correct to the best of my
knowledge. I understand that any false information or omission of information relating to residency and
citizenship is cause for suspension from West Virginia Northern Community College. I will acquaint
myself with and abide by the student code of conduct, including compliance with the Drug-Free Schools
and Communities Act, and other requirements governing the academic and social standards of West
Virginia Northern Community College.
__________________________________________ ____________________
Signature
Date
Please select Training Area on back.
Course Title
Credits
Cost
Total
Payment Enclosed: Check $________ (Please make payable to WVNCC.)
Credit Card - circle one: Master Card, Visa, Discover, American Express
Print name on Credit Card: ____________________________ Number: ______________________
Signature of Card Holder: _ ___________________________ Exp. Date:_____________________
Equal Opportunity Policy: West Virginia Northern Community College, pursuant to the requirements of Titles IV, VI, VII of the Civil Rights Act of 1964: Title IX of
the Educational Amendment of the 1972, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, does not discriminate against
applicants, employees, or students on the basis of race, color, religion, sex, disability, age, sexual orientation, or national origin in its employment policies and/or
educational programs or activiites, including admission to such.
over
10/14
CONTINUING EDUCATION SKILL SETS AND TRAINING AREAS
Instructions: Northern’s continuing education department helps individuals upgrade their job skills, enhance their professional
knowledge and development, plus explore personal interests. It also helps employers improve the quality of their workforce.
Place a check mark in the box next to the area you wish to pursue.
AREA OF INTEREST
LOCATION
*/**GRANT
APPROVED
TRAINING
CODE
r Administrative Medical Specialist
Online
HEAPSW
618
r Administrative Professional with Microsoft Office Master
Online
HEAPSW
611
r American Institute of Banking
All Campuses
r Basic Welding
Online
HEAPSW
642
r Biofuel Production Operations
Online
HEAPSW
629
r Business and industry arranged classes
Arranged
r Certified Indoor Environmentalist
Online
HEAPSW
626
r Certified Mediator
Online
HEAPSW
624
r Certified Protection Officer
All Campuses
HEAPSW
619
r Chemical Plant Operations
Online
r Child Development Associate Training Certification
All Campuses
r Clinical Dental Assistant
Online
r Entrepreneurial and e-Business Skills
All Campuses
r Home Health Direct Care Assistant
Weirton only
r Human Resource Professional
601
700
HEAPSW
631
HEAPSW/VA
622
HEAPSW
628
307S
VA
680
Online
HEAPSW
636
r iPhone/iPad (iOs) Application Developer
Online
HEAPSW
644
r Management Professional Training
Online
635
r Manufacturing Management/AMA
Independent Study
660
r Medical Coding & Billing (NHA)
Online
HEAPSW
638
r Medical Transcription
Online
HEAPSW
620
r Microsoft Office Applications Certification
Online
HEAPSW
639
r Natural Gas Plant Operations
Online
HEAPSW
634
r Paramedic Technology (TBA)
Wheeling only
HEAPSW/VA
609P
r Peachtree Accounting Software Training/Business
Wheeling only
r Pharmacy Technician
Online
r Phlebotomy Technician ($25 Application Fee Required)
Wheeling only
650
HEAPSW
623
HEAPSW/VA
605P
641
r Power Plant Operations
r Other individual course/s: Please List
Online
r Table Gaming
Weirton & Wheeling
HEAPSW/VA
687
r Veterinary Assistant Training
Online
HEAPSW
617
r Webmaster Certification Training
Online
HEAPSW
632
HEAPSW/VA
615
r WV Real Estate Pre Licensing Exam Prep
*Subject to change. Check with campus couselor at time of
application. HEAPSW - Higher Education Adult Part-time Student
Workforce Development Component is for West Virginia residents
only. The HEAPSW Grant Program is for West Virginia students
who desire to continue their education on a part-time basis.
HEAPSW application submission required.
699
Wheeling/Online
**Subject to change. Check with campus counselor at time of
application. Program is approved for VA benefits. See campus
counselor or VA coordinator.
IMPORTANT INFORMATION: If you have been convicted of a
felony or misdemeanor, send a confidential letter of explanation
to the Continuing Education Coordinator. Some State/National
Testing Boards reserve the right to determine eligibility for
licensing credentialing. Male students under age 26 must be
registered with selective service.
A NON-REFUNDABLE application fee of $25.00 must accompany this application if you are applying for the Phlebotomy program.
Submission of application does not constitute admission to a program.
This application can be returned to any WVNCC campus or mailed to:
Campus Service Center
West Virginia Northern Community College
1704 Market St.
Wheeling, WV 26003