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Continuing Education Center Certificate Program Application

1. Date Accepted (for Office use only)

To register using this form either:

• Fill in the form online and print it or print the form and fill it in and bring it to our office or
• Fill in the form online and print it or print the form and fill it in and fax it to 678-915-7490 or
• Fill in the form online and print it or print the form and fill it in and mail the completed registration form to:

Continuing Education Center
Southern Polytechnic State University
1100 South Marietta Parkway, Building #WE
Marietta, Georgia 30060-2896

Choose the Certificate Program of Interest

1. A+/Net+ Certificate
2. AutoCAD Certificate
3. CISCO Certified Network Associate (CCNA)
4. Certified Information Systems Security Professional (CISSP) Certification
5. E-Business Solutions in Java Certificate
6. Embedded Systems Software Certificate
7. Linux+ Certificate
8. Microsoft Certified Application Developer (MCAD)
9. Microsoft Certified Systems Administrator 2003 Certificate
10. Microsoft Office Specialist
11. Oracle 10g Database Certificate
12. Professional Project Management Certificate

Personal Information

1. Date of Application
2. First Name
3. Middle Name
4. Last Name
5. Street Address
6. City
7. State
8. Zip
9. Daytime Phone
10. Alternate Phone
11. Fax
12. E-mail

Financial support provided by:

1. Organization
2. VA
3. VA Voc-Rehab
4. WIA county
5. DOL Voc-Rehab
6. Other
7. Contact's Name
8. Contact's Phone #
9.  
10. * These programs are not eligible for Financial Aid. *

Educational Background

1. High School Diploma
2. No
3. Yes
4.  
5. First degree earned
6. First major
7. First college attended
8. Date first degree was earned
9. Second degree earned
10. Second major
11. Second college attended
12. Date second degree was earned
13. Other colleges attended / degrees earned / certificates earned
    

Computer Experience

1. Experience Level
2. 0 to 3 years
3. 4 to 6 years
4. 7 or more years
5.  
6. Which operating system(s) are you familiar with? (check all that apply or "N/A"):
7. Windows 2000
8. Windows 2003
9. Windows NT
10. Windows Vista
11. Windows XP
12. N/A
13. Other Operating Systems
14.  
15. Which word processing program(s) are you familiar with? (check all that apply or "N/A"):
16. Word 97
17. Word 2000
18. Word XP
19. Word 2003
20. Word 2007
21. N/A
22. Other Word Processing Software
23.  
24. Which Spreadsheet program(s) are you familiar with? (check all that apply or "N/A"):
25. Excel 97
26. Excel 2000
27. Excel XP
28. Excel 2003
29. Excel 2007
30. N/A
31. Other Spreadsheet Software
32.  
33. Which Database program(s) are you familiar with? (check all that apply or "N/A"):
34. Access
35. MySQL
36. Oracle
37. PostgreSQL
38. SQL Server
39. N/A
40. Other Database Software
41.  
42. Microsoft Project 2003 or higher
43. N/A
44. No
45. Yes
46.  
47. Other Relevant Software and Versions

Program Interest

1. How did you learn of this program?
2. Email request
3. Faculty/Staff
4. Links Catalog
5. Mailing
6. Marquee
7. Internet / Search
8. Other

Reasons for Applying

1. Program Begin DateCourse #

Method of Payment

1. *** There is a $10.00 non-refundable application fee ***
2.  
3. Cash Check Mastercard VISA American Express
4. Card Number
5. Expiration Date
6. Name as it appears on the card
7. Signature

Work Experience

1. Please provide your work experience (If you are filling the form out online you can copy and paste your resumé. If you are printing this form to fill out by hand, please attach a copy of your resumé.)

Continuing Education Center | 1100 South Marietta Parkway, Building #WE | Marietta, GA | 30060 | 678-915-7240