I hereby apply for enrollment in Daymar Institute subject to the provisions of the Institute's current catalog. The information on this Application for Admission is accurate, complete and true and any inaccurate, incomplete or false statement will entitle the Institute to deny admission to me.

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*Fields with a star are required.

Personal Information

Campus Location *
Please Select
First Name *
Middle Name

Last Name *
Maiden Name

Address *
City *

State *
Zip *

Home Telephone *
    Cell Phone
   
Work Phone
    Ext

Primary Email Address *
Other Email Address

Gender *
Gender Female Male

Date of Birth *
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Driver's License Number
Driver's License State
Emergency Contact Name *
Phone Number *
    Relation to Applicant *
Emergency Contact Address *
City *
State *
Zip *

Responses to the following questions are voluntary and are used for state reporting purposes only.

  Veteran Yes No
Disabled
Yes No
Citizen
Yes No If no, Alien No.
Marital Status
-- Select One -- Single Separated Married Divorced Widow Race
-- Select One -- African American White (Caucasian) Hispanic Other Other Race

Transportation Information

Select all that apply
(hold ctrl to select more than one)
-- Select -- Bicycle Bus Fellow Student Friend Motorcycle My Car Relative Taxi Walk Other Other Transportation

Academic Information

Program of Interest *
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Class Time Preference *
-- Select -- Afternoon Evening Morning Weekend Online Highest Level of Previous Education *
-- Select -- High School Graduate GED Some College College Graduate Name of High School Attended
Address
City
State
Zip
Date of Graduation
Date of GED Test
Testing Center

Name of Previous College
Address
City
State
Zip

Admission to, employment by and promotion at Daymar Institute shall be on the basis of merit, and there shall be no discrimination on the basis of race, color, creed, sex, handicap, or national origin. Daymar Institute provides equal opportunity to all persons.

Applicant's Initials *