CompTIA A+ Certification Program Application
University of Minnesota
Technology Empowerment Center
2001 Plymouth Ave. N., Suite 106
Minneapolis, MN 55411
Phone: 612-624-3704
https://diversity.umn.edu/bced/a-plus
First Name
MI
Last Name
Home Address
City
Phone Number
Email Address
DOB
State
What is your ethnicity?
☐African American
☐Caucasian
☐African
☐Chicano/Latino
☐Asian/Southeast Asian/Pacific Islander
☐Multi-ethnic
☐American Indian/Native American
☐Other
How would you rate your computer skills?
☐No experience
☐Beginner
☐Intermediate
What is your educational background?
☐GED ☐HS Diploma ☐Some College (Non-Degree) ☐Associate Degree
☐Graduate Degree
Zip
Gender
(Which gender do
you self-identify as?)
☐Male
☐Female
☐Other
☐Advanced
☐BA/BS
What is your technical background? Please check all of those that apply.
(Lack of any of the options listed does not eliminate your eligibility.)
☐Basic Computer Knowledge ☐Microsoft Office ☐Internet ☐Windows ☐Mac
☐Computer Troubleshoot/Repair ☐Networking ☐DOS
What are your professional goals?
☐PC
What are your reasons to become involved with this program?
Are you a Veteran of U.S. Armed Forces?
☐Yes ☐No
Do you have a disability or health condition that requires accommodations?
☐Yes ☐No
The BCED values diversity and provides equal access for all of our programs and will assist with
implementing disability accommodations (for participants).
Agreement/Disclaimer
Please initial by each of the agreements below:
1. _________ I will not miss more than 2 unexcused days.
2. _________ I consent to have my picture or video taken while attending the computer classes to
use for promotional and informational purposes through a variety of communication venues.
3. _________ I understand that Technology Empowerment Center is not responsible for any injuries,
damages, penalties, or losses, including legal costs and expenses, incurred by us or any other
person caused by the transportation, installation, use of or any other matters relating to the
computer.
4. _________ The statements on this application are true, complete and correct to the best of my
knowledge.
Signature
I understand the terms of the program and verify that all of the information provided above is true.
Applicant's Printed Name: _____________________________________
Applicant's Signature: _________________________________________ Date: _____________
For your convenience and to ensure a faster turnaround, you may also apply online at:
http://diversity.umn.edu/bced/a-plus
Application should be mailed to:
Office for Business & Community Economic Development
Attn: Nam Nguyen
2221 University Avenue SE, Suite 136
Minneapolis, MN 55414
E-mail: nguye186@umn.edu | 612-624-8891 (office) | 612-625-9056 (fax)
Application must be received on or before October 9th.