Application

Name:	(e.g. Last, First)
Sex:	Male Female
Date of Birth:	(e.g. xx/xx/xxxx)
Social Security Number:	(e.g. xxx-xx-xxxx)
Driver's License Number:
Expiration Date:	(e.g. xx/xx/xxxx)
Ethnic Identity:	Refuse to State American Indian Asiam/Pacific Islander Black Hispanic Other White
Street Address:
Address (cont.):
City:
State:
Zip Code:
Country:
Work Phone:	(e.g. xxx-xxx-xxxx)
Cell Phone:	(e.g. xxx-xxx-xxxx)
Home Phone:	(e.g. xxx-xxx-xxxx)
E-mail:
Class:	Electricial Electrical CE Core (Only IA) Carpentry Painting Plumbing Level Core IA IB IC IIA IIB IIC IIIA IIIB IIIC IVA IVB IVC VA VB VC CE Option #1 CE Option #2
Class Location:	Hayward Concord San Jose Fresno Turlock (For testing and "hands-on" training)
You will automatically receive a copy of your grade and progress report.
Send a copy of my grades and progress to my employer?	No Yes	Note: If Yes is selected, you must fill out the employer's name and address below
Employer:
Employer's Address:
Employers City:
Employers State:
Employer Zip Code:
Bill Employer:	No Yes	Note: If Yes is selected, your employer will be contacted and must confirm this option
Employer Supervisor:
Referred by:	Select one please... Employer Student Mailing Internet Printed Ad Yellow Pages Radio Ad Other

If you have questions or have not received a confirmation of your registration, please call 510-785-2282 or 800-678-6669.

Note: In order to receive a completion confirmation letter (required by the State of California for registered electrical trainees), CCTC must receive full payment for all classes.