Online Registration Form

Please provide the following student contact information:

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
E-mail
Telephone	000-000-0000

Please identify and describe yourself:

Date of Birth

Choose one of the following options: Which class session would you like to register for?:

January 2006 March 2006 June 2006 August 2006 September 2006 January 2007 March 2007 June 2007 August 2007 September 2007

Enter today's date (XX/XX/XXXX)

Is this your first degree? Please select one  Yes No

The following information is requested by the US Government and optional. Please enter your sex and Ethnic Background: 

Male
Female

Please select one:
Non Resident Alien Black - Non Hispanic American Indian and Alaskan Asian and Pacific Islander Hispanic White - Non Hispanic

 

Please enter your Social Security Number or State Driver's License Number (required by the State Board of Proprietary School Registration)

(Do not enter any dashes)

If you are currently connected with a florist, please fill in the following information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Choose one of the following options: Tuition will be paid by:

Student Parent Guardian Govt Agency

If person other than student is paying tuition, please provide the following information:

First Name
Last Name
Middle Initial
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

Digital signature of payee: Please type your name

As required by the State Board of Proprietary School Registration Administrative Rule 3332-1-09, "it is the schools responsibility to determine with reasonable certainty, in advance of the acceptance of a prospective student's enrollment, that the student meets the minimum basic admissions qualifications to successfully assimilate the program they intend to enter." Please answer this question: Why would you like to enter the floral industry?

What do you hope to accomplish after graduating from our course?

Add the following amounts: Twenty-five dollars, plus six dollars, plus one dollar and sixty-three cents?

Multiply one dollar and twenty cents by the number four. What is the answer?

Divide thirty-five dollars by the number four. What is the answer?

What is fifteen percent of seventy-five dollars?

Do you have any health conditions or physical limitations which would prevent you from successfully completing the course? Please select one:

Yes
No

If Yes, please explain:

By typing my name in below, I declare that I have completed all answers by myself to the best of my ability. I also confirm that no other person persuaded my answers in anyway.

Method of registration payment?

Visa Via PayPal MasterCard American Express Diners Club Carte Blanche Mailing in Check