Date Rec’d ________________

 

Date Processed ____________

 

 

NON-DEGREE CERTIFICATE APPLICATION

Hampton Roads Hospitality Education and Training Initiative

4300 George Washington Highway

Portsmouth, Virginia 23702

Tele: 757-396-6944; Fax: 757-396-6583

 

PLEASE PRINT OR TYPE AND COMPLETE ALL INFORMATION REQUESTED

 

1.  Course Selection:

□  Lodging Management (twice a week for 20 weeks)

□  Food Service Management (once a week for 16 weeks)

 

  1. Preferred Time and Location:

□  9:00 AM to Noon

□  6:30 –  9:30 PM

 

                □  Norfolk              □  Portsmouth                       □  Virginia Beach                 

□  Hampton           □  Newport News                 □  Williamsburg

 

  1. Are you working in the Hospitality Industry?

□  Yes                     □  No                      If yes, where? _________________

  1. Please provide the following contact information:

Name _________________________________

Street Address __________________________

Apt ______________

City _______________________

State __________

Zip ________________

Daytime Phone _________________________

Home Phone ___________________________

Fax __________________________________

Social Security # ________________________

5.     Gender:  □  Male                   □  Female

6.     Date of Birth (mm/dd/yy) __________________

7.     Legal State of Residence ___________________

8.     Marital Status:  □  Divorced               □  Married             □  Single                □  Widower

9.     Race/Ethnic Identification (for Federal reporting purposes only):

□  African American (non-Hispanic)                □  American Indian or Alaskan Native

□  Asian or Pacific Islander                                □  Hispanic            □  White (non-Hispanic)

□  Other (please specify) ________________

10.   Highest grade completed: _______________               School Name: ________________

  1. Employment: List your last three (3) jobs, starting with your most current:

Start Date (mm/dd/yy) _____________                         End Date (mm/dd/yy) _____________

 

Company _______________________________

 

Job Title _______________________________       Salary ________________

 

 

Start Date (mm/dd/yy) _____________                         End Date (mm/dd/yy) _____________

 

Company _______________________________

 

Job Title _______________________________       Salary ________________

 

 

Start Date (mm/dd/yy) _____________                         End Date (mm/dd/yy) _____________

 

Company _______________________________

 

Job Title _______________________________       Salary _________________

 

12.   Referral Source:  □  Radio   □  Newspaper       □  Television         □  Friend

 

□  Other (please specify) ______________________

 

13.   Person to contact in case of emergency ________________________________

       

        Phone ____________________

 

  1. SPECIAL NEEDS: Check all that apply

□  Transportation                 □  Child-care        

□  Special access needs (please specify) _________________________________

                                                ___________________________________________

                                                ___________________________________________

 

  1. Comments and/or Questions: _______________________________________

_________________________________________________________________

_________________________________________________________________

 

 

TO BE COMPLETED BY NON-US CITIZENS ONLY

 

Country of citizenship __________________

 

Permanent Resident?  □  Yes     □  No      If No, what is your visa status? ______________________

 

 

I certify that the answers to the statements are true and correct to the best of my knowledge and that I will abide by the rules and regulations governing the Hampton Roads Hospitality Education and Training Initiative.

 

 

Signature of Applicant: ____________________

 

 

Date: _______________